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201706157

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UWHC,UWMF,

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

CSC GYN INPT-OP EMA-CO (14D1, 2 and 8) VER 1-11-17 (HL 1502)

CSC GYN INPT-OP EMA-CO (14D1, 2 and 8) VER 1-11-17 (HL 1502) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GYN


CSC GYN INPT/OP EMA-CO (14D:1, 2, AND 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: Escobar PF, et al. Gynecol Oncol 2003;91:552-7.
Treatment Plan Summary
DISEASE: Gestational Trophoblastic Neoplasm (Adjuvant/Advanced);
THERAPY: dactinomycin 500 mcg IV Day 1 and Day 2, etoposide 100 mg/m2 IV Day 1 and Day 2, methotrexate 100 mg/m2 IV push
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, vinCRIStine 1 mg/m2 (maximum 2mg) IV Day 8, cyclophosphamide 600 mg/m2 IV
day 8; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 14 days; COURSE: Treatment continued 1 or 2 courses 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
BILIRUBIN, TOTAL
ONCE Starting when released
AST/SGOT
ONCE Starting when released
HCG, QUANTITATIVE
ONCE Starting when released, Routine
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
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, 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) 12 mg in sodium chloride 0.9 % 50 mL bag
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Zztestonc,Edward E [2435061]
6/6/2017 5:36:15 PM Page 1 of 18
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

12 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 12 mg
12 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 Day 2. Administer with non-PVC tubing.
methotrexate PF (TREXALL) injection 200 mg
200 mg (100 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Day 1 only: IV push rate 10 mg/minute.
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 only: Administer in 250mL D5W.
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 15 mg in dextrose 5 % 100 mL bag
15 mg, Intravenous, EVERY 12 HOURS PRN, 4 doses Starting S+1 at 0000, Following methotrexate
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)
dexamethasone (DECADRON) 4 MG tab
Take 2 tabs by mouth one time daily. Take on Day 3 through 4., 8 mg, Disp-4 tab, R-5, 1 X DAILY starting S
Dispense only if patient discharged after Day 2 therapy.
TBO-filgrastim (GRANIX) 300 MCG/0.5ML soln prefilled syringe
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.
Take Home Medications
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Zztestonc,Edward E [2435061]
6/6/2017 5:36:15 PM Page 2 of 18
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

ondansetron (ZOFRAN) 8 MG tab
Take 1 tab orally 2x daily for 2 days after Day 8 chemo then every 8h as needed for nausea, Disp-30 tab, R-5, starting S, Local
Printer
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: cyclophosphamide and vinCRIStine for
120 minutes.
DAY 15 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Magnesium,
Creatinine, 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 Day 2, etoposide 100 mg/m2 IV Day 1 and Day 2, methotrexate 100 mg/m2 IV push
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, vinCRIStine 1 mg/m2 (maximum 2mg) IV Day 8, cyclophosphamide 600 mg/m2 IV
day 8; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 14 days; COURSE: Treatment continued 1 or 2 courses 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 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S 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 1,500/µL or Platelets less than or equal to 100K/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 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
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Zztestonc,Edward E [2435061]
6/6/2017 5:36:15 PM Page 3 of 18
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
vinCRIStine (ONCOVIN) 2 mg in sodium chloride 0.9 % 25 mL bag
2 mg (1 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released, Administer
over 3-5 Minutes
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
cyclophosphamide (CYTOXAN) 1,200 mg in sodium chloride 0.9 % 250 mL bag
1,200 mg (600 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 6/20/2017 through 7/3/2017 (14 days), Planned
Day 1 and Day 2 Inpatient, Cycle 2 – Planned for 6/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gestational Trophoblastic Neoplasm (Adjuvant/Advanced);
THERAPY: dactinomycin 500 mcg IV Day 1 and Day 2, etoposide 100 mg/m2 IV Day 1 and Day 2, methotrexate 100 mg/m2 IV push
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, vinCRIStine 1 mg/m2 (maximum 2mg) IV Day 8, cyclophosphamide 600 mg/m2 IV
day 8; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 14 days; COURSE: Treatment continued 1 or 2 courses 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
AST/SGOT
ONCE Starting when released
HCG, QUANTITATIVE
ONCE Starting when released, Routine
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.
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Zztestonc,Edward E [2435061]
6/6/2017 5:36:15 PM Page 4 of 18
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 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
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, 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) 12 mg in sodium chloride 0.9 % 50 mL bag
12 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 12 mg
12 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 Day 2. Administer with non-PVC tubing.
methotrexate PF (TREXALL) injection 200 mg
200 mg (100 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Day 1 only: IV push rate 10 mg/minute.
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 only: Administer in 250mL D5W.
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 15 mg in dextrose 5 % 100 mL bag
15 mg, Intravenous, EVERY 12 HOURS PRN, 4 doses Starting S+1 at 0000, Following methotrexate
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
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Zztestonc,Edward E [2435061]
6/6/2017 5:36:15 PM Page 5 of 18
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: cyclophosphamide and
vinCRIStine for 120 minutes.
DAY 15 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Magnesium,
Creatinine, AST, ßHCG; CHEMOTHERAPY: Inpatient Admit per physicians discretion.
Day 8 Outpatient, Cycle 2 – Planned for 6/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gestational Trophoblastic Neoplasm (Adjuvant/Advanced);
THERAPY: dactinomycin 500 mcg IV Day 1 and Day 2, etoposide 100 mg/m2 IV Day 1 and Day 2, methotrexate 100 mg/m2 IV push
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, vinCRIStine 1 mg/m2 (maximum 2mg) IV Day 8, cyclophosphamide 600 mg/m2 IV
day 8; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 14 days; COURSE: Treatment continued 1 or 2 courses 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 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S 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 1,500/µL or Platelets less than or equal to 100K/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 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
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Zztestonc,Edward E [2435061]
6/6/2017 5:36:15 PM Page 6 of 18
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
Treatment Medications
vinCRIStine (ONCOVIN) 2 mg in sodium chloride 0.9 % 25 mL bag
2 mg (1 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released, Administer
over 3-5 Minutes
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
cyclophosphamide (CYTOXAN) 1,200 mg in sodium chloride 0.9 % 250 mL bag
1,200 mg (600 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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
Treatment Plan Summary
DISEASE: Gestational Trophoblastic Neoplasm (Adjuvant/Advanced);
THERAPY: dactinomycin 500 mcg IV Day 1 and Day 2, etoposide 100 mg/m2 IV Day 1 and Day 2, methotrexate 100 mg/m2 IV push
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, vinCRIStine 1 mg/m2 (maximum 2mg) IV Day 8, cyclophosphamide 600 mg/m2 IV
day 8; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 14 days; COURSE: Treatment continued 1 or 2 courses 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
AST/SGOT
ONCE Starting when released
HCG, QUANTITATIVE
ONCE Starting when released, Routine
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
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
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Zztestonc,Edward E [2435061]
6/6/2017 5:36:15 PM Page 7 of 18
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

150 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, 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) 12 mg in sodium chloride 0.9 % 50 mL bag
12 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 12 mg
12 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 Day 2. Administer with non-PVC tubing.
methotrexate PF (TREXALL) injection 200 mg
200 mg (100 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Day 1 only: IV push rate 10 mg/minute.
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 only: Administer in 250mL D5W.
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 15 mg in dextrose 5 % 100 mL bag
15 mg, Intravenous, EVERY 12 HOURS PRN, 4 doses Starting S+1 at 0000, Following methotrexate
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); CHEMOTHERAPY ROOM APPOINTMENT: cyclophosphamide and vinCRIStine for
120 minutes.
DAY 15 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Magnesium,
Creatinine, AST, ßHCG; CHEMOTHERAPY: Inpatient Admit per physicians discretion.
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Zztestonc,Edward E [2435061]
6/6/2017 5:36:15 PM Page 8 of 18
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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 Day 2, etoposide 100 mg/m2 IV Day 1 and Day 2, methotrexate 100 mg/m2 IV push
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, vinCRIStine 1 mg/m2 (maximum 2mg) IV Day 8, cyclophosphamide 600 mg/m2 IV
day 8; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 14 days; COURSE: Treatment continued 1 or 2 courses 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 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S 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 1,500/µL or Platelets less than or equal to 100K/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 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
vinCRIStine (ONCOVIN) 2 mg in sodium chloride 0.9 % 25 mL bag
2 mg (1 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released, Administer
over 3-5 Minutes
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
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Zztestonc,Edward E [2435061]
6/6/2017 5:36:15 PM Page 9 of 18
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

cyclophosphamide (CYTOXAN) 1,200 mg in sodium chloride 0.9 % 250 mL bag
1,200 mg (600 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gestational Trophoblastic Neoplasm (Adjuvant/Advanced);
THERAPY: dactinomycin 500 mcg IV Day 1 and Day 2, etoposide 100 mg/m2 IV Day 1 and Day 2, methotrexate 100 mg/m2 IV push
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, vinCRIStine 1 mg/m2 (maximum 2mg) IV Day 8, cyclophosphamide 600 mg/m2 IV
day 8; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 14 days; COURSE: Treatment continued 1 or 2 courses 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
AST/SGOT
ONCE Starting when released
HCG, QUANTITATIVE
ONCE Starting when released, Routine
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
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, 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) 12 mg in sodium chloride 0.9 % 50 mL bag
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Zztestonc,Edward E [2435061]
6/6/2017 5:36:15 PM Page 10 of 18
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

12 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 12 mg
12 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 Day 2. Administer with non-PVC tubing.
methotrexate PF (TREXALL) injection 200 mg
200 mg (100 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Day 1 only: IV push rate 10 mg/minute.
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 only: Administer in 250mL D5W.
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 15 mg in dextrose 5 % 100 mL bag
15 mg, Intravenous, EVERY 12 HOURS PRN, 4 doses Starting S+1 at 0000, Following methotrexate
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); CHEMOTHERAPY ROOM APPOINTMENT: cyclophosphamide and vinCRIStine for
120 minutes.
DAY 15 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Magnesium,
Creatinine, 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 5:36:15 PM Page 11 of 18
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 Day 2, etoposide 100 mg/m2 IV Day 1 and Day 2, methotrexate 100 mg/m2 IV push
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, vinCRIStine 1 mg/m2 (maximum 2mg) IV Day 8, cyclophosphamide 600 mg/m2 IV
day 8; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 14 days; COURSE: Treatment continued 1 or 2 courses 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 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S 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 1,500/µL or Platelets less than or equal to 100K/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 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
vinCRIStine (ONCOVIN) 2 mg in sodium chloride 0.9 % 25 mL bag
2 mg (1 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released, Administer
over 3-5 Minutes
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
cyclophosphamide (CYTOXAN) 1,200 mg in sodium chloride 0.9 % 250 mL bag
1,200 mg (600 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
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Zztestonc,Edward E [2435061]
6/6/2017 5:36:15 PM Page 12 of 18
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 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
Treatment Plan Summary
DISEASE: Gestational Trophoblastic Neoplasm (Adjuvant/Advanced);
THERAPY: dactinomycin 500 mcg IV Day 1 and Day 2, etoposide 100 mg/m2 IV Day 1 and Day 2, methotrexate 100 mg/m2 IV push
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, vinCRIStine 1 mg/m2 (maximum 2mg) IV Day 8, cyclophosphamide 600 mg/m2 IV
day 8; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 14 days; COURSE: Treatment continued 1 or 2 courses 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
AST/SGOT
ONCE Starting when released
HCG, QUANTITATIVE
ONCE Starting when released, Routine
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
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, 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) 12 mg in sodium chloride 0.9 % 50 mL bag
12 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 12 mg
12 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 5:36:15 PM Page 13 of 18
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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 Day 2. Administer with non-PVC tubing.
methotrexate PF (TREXALL) injection 200 mg
200 mg (100 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Day 1 only: IV push rate 10 mg/minute.
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 only: Administer in 250mL D5W.
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 15 mg in dextrose 5 % 100 mL bag
15 mg, Intravenous, EVERY 12 HOURS PRN, 4 doses Starting S+1 at 0000, Following methotrexate
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); CHEMOTHERAPY ROOM APPOINTMENT: cyclophosphamide and vinCRIStine for
120 minutes.
DAY 15 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Magnesium,
Creatinine, 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 Day 2, etoposide 100 mg/m2 IV Day 1 and Day 2, methotrexate 100 mg/m2 IV push
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, vinCRIStine 1 mg/m2 (maximum 2mg) IV Day 8, cyclophosphamide 600 mg/m2 IV
day 8; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 14 days; COURSE: Treatment continued 1 or 2 courses past the first
normal hCG level.
IV Access
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Zztestonc,Edward E [2435061]
6/6/2017 5:36:15 PM Page 14 of 18
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S 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 1,500/µL or Platelets less than or equal to 100K/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 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
vinCRIStine (ONCOVIN) 2 mg in sodium chloride 0.9 % 25 mL bag
2 mg (1 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released, Administer
over 3-5 Minutes
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
cyclophosphamide (CYTOXAN) 1,200 mg in sodium chloride 0.9 % 250 mL bag
1,200 mg (600 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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 5:36:15 PM Page 15 of 18
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: Gestational Trophoblastic Neoplasm (Adjuvant/Advanced);
THERAPY: dactinomycin 500 mcg IV Day 1 and Day 2, etoposide 100 mg/m2 IV Day 1 and Day 2, methotrexate 100 mg/m2 IV push
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, vinCRIStine 1 mg/m2 (maximum 2mg) IV Day 8, cyclophosphamide 600 mg/m2 IV
day 8; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 14 days; COURSE: Treatment continued 1 or 2 courses 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
AST/SGOT
ONCE Starting when released
HCG, QUANTITATIVE
ONCE Starting when released, Routine
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
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, 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) 12 mg in sodium chloride 0.9 % 50 mL bag
12 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 12 mg
12 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.
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Zztestonc,Edward E [2435061]
6/6/2017 5:36:15 PM Page 16 of 18
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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 Day 2. Administer with non-PVC tubing.
methotrexate PF (TREXALL) injection 200 mg
200 mg (100 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Day 1 only: IV push rate 10 mg/minute.
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 only: Administer in 250mL D5W.
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 15 mg in dextrose 5 % 100 mL bag
15 mg, Intravenous, EVERY 12 HOURS PRN, 4 doses Starting S+1 at 0000, Following methotrexate
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); CHEMOTHERAPY ROOM APPOINTMENT: cyclophosphamide and vinCRIStine for
120 minutes.
DAY 15 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Magnesium,
Creatinine, AST, ßHCG; CHEMOTHERAPY: Inpatient Admit per physicians discretion.
Day 8 Outpatient, Cycle 6 – Planned for 8/22/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gestational Trophoblastic Neoplasm (Adjuvant/Advanced);
THERAPY: dactinomycin 500 mcg IV Day 1 and Day 2, etoposide 100 mg/m2 IV Day 1 and Day 2, methotrexate 100 mg/m2 IV push
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, vinCRIStine 1 mg/m2 (maximum 2mg) IV Day 8, cyclophosphamide 600 mg/m2 IV
day 8; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 14 days; COURSE: Treatment continued 1 or 2 courses 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
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Zztestonc,Edward E [2435061]
6/6/2017 5:36:15 PM Page 17 of 18
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 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S 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 1,500/µL or Platelets less than or equal to 100K/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 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
vinCRIStine (ONCOVIN) 2 mg in sodium chloride 0.9 % 25 mL bag
2 mg (1 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released, Administer
over 3-5 Minutes
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
cyclophosphamide (CYTOXAN) 1,200 mg in sodium chloride 0.9 % 250 mL bag
1,200 mg (600 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,Edward E [2435061]
6/6/2017 5:36:15 PM Page 18 of 18
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org