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201706157

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100

UWHC,UWMF,

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

CSC GYN Intraperitoneal Cisplatin(21D2) Paclitaxel(21D1,8) VER 1-11-17 (HL 1773)

CSC GYN Intraperitoneal Cisplatin(21D2) Paclitaxel(21D1,8) VER 1-11-17 (HL 1773) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GYN


CSC GYN INTRAPERITONEAL CISPLATIN (21D:2)/PACLITAXEL (21D:1,8) VER: 1-11-17 – Properties
Pre-Cycle – 5/30/2017 through 6/5/2017 (7 days), Planned
Day 1, Pre-Cycle – Planned for 5/30/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian (stage III), Primary Peritoneal Carcinoma, Fallopian Tube Cancer (Adjuvant); THERAPY: PACLItaxel 175 mg/m2
IV (over 3 hours) Day 1, CISplatin 75 to 100 mg/m2 intraperitoneal Day 2 and PACLItaxel 60 mg/m2 intraperitoneal Day 8; CYCLE
LENGTH: 21 days; COURSE: 6 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Routine
CALCIUM
Expected-S Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S Approximate, Expires-S+365, Routine
CA 125
Expected-S Approximate, Expires-S+365, Routine
For ovarian, fallopian tube, and primary peritoneal cancer.
CREATININE
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
Take 5 tablets 12&6h prior to 1st dose of PACLItaxel., Disp-10 tab, R-0, starting S
aprepitant (EMEND) 80 MG cap
Take 1 cap by mouth one time daily. Take for 2 days following CISplatin on Day 3 and 4., 80 mg, Disp-2 cap, R-5, 1 X DAILY
starting S
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed for nausea/vomiting., 8 mg, Disp-30 tab, R-5, EVERY 8 HOURS PRN starting S,
Local Printer
Cycle 1 – 6/6/2017 through 6/26/2017 (21 days), Planned
Day 1, Cycle 1 – Planned for 6/6/2017
Treatment Plan Information
Reference Information (1)
OVARIAN CANCER/PRIMARY PERITONEAL CARCINOMA/FALLOPIAN TUBE CARCINOMA: Armstrong DK, et al. N Engl J Med
2006;354:34-43.
Treatment Plan Summary
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Zztestonc,Edward E [2435061]
6/6/2017 5:40:12 PM Page 1 of 34
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

DISEASE: Ovarian (stage III), Primary Peritoneal Carcinoma, Fallopian Tube Cancer (Adjuvant); THERAPY: PACLItaxel 175 mg/m2
IV (over 3 hours) Day 1, CISplatin 75 to 100 mg/m2 intraperitoneal Day 2 and PACLItaxel 60 mg/m2 intraperitoneal Day 8; CYCLE
LENGTH: 21 days; COURSE: 6 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,500/µL or Platelets less than 100K/µL or Creatinine greater than 2 mg/dL.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 18 mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
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Zztestonc,Edward E [2435061]
6/6/2017 5:40:12 PM Page 2 of 34
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN Starting when released Until Discontinued, If PO not taken at home.
For use in patients who did not take dexamethasone at home.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 350 mg in dextrose 5 % 500 mL non-PVC bag
350 mg (175 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 180 minutes. Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be
treated in a location to optimize emergency care. See Emergency Medications.
** Rush dextrose primed line with 18 mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes. Use non-PVC tubing and 0.2 or 0.22
micron in-line filter during administration.
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
Take 3 tabs 12&6 hrs prior to 2nd PACLItaxel IV dose and 2 tabs once daily on Days 3&4 after CISplatin., Disp-10 tab, R-0,
starting S
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: CISplatin (intraperitoneal administration) with pre and post hydration for 510 minutes.
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally); CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel (intraperitoneal administration) for
240 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC, Calcium, Phosphate, Magnesium, CA-
125, Creatinine, Total Bilirubin, Potassium; CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel (IV) for 210 minutes.
Day 2, Cycle 1 – Planned for 6/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian (stage III), Primary Peritoneal Carcinoma, Fallopian Tube Cancer (Adjuvant); THERAPY: PACLItaxel 175 mg/m2
IV (over 3 hours) Day 1, CISplatin 75 to 100 mg/m2 intraperitoneal Day 2 and PACLItaxel 60 mg/m2 intraperitoneal Day 8; CYCLE
LENGTH: 21 days; COURSE: 6 cycles.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
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Zztestonc,Edward E [2435061]
6/6/2017 5:40:12 PM Page 3 of 34
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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.
Flush IP access per UWHC guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush intraperitoneal port with 20 mL prior to de-accessing.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, ONCE, 1 dose Starting when released
Flush intraperitoneal port with 10 mL prior to de-accessing.
Hydration
sodium chloride 0.9 % infusion 2,000 mL
at 1,000 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 2000 mL over 2 hours prior to CISplatin IP instillation.
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
lidocaine (LMX) 4% topical dressing kit
Topical, ONCE, 1 dose Starting when released
Please have available when accessing intraperitoneal port. 1 gm per 5cm of skin, topically and covered with occlusive dressing, 60
minutes prior to IP port access.
lidocaine 1 % vial
10 mg, Subcutaneous, ONCE, 1 dose Starting when released
0.5mL-1mL intradermal prior to intraperitoneal port access. (RN to obtain from floorstock.)
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting when released
IV push rate 10 mg/minute. Give 30 minutes prior to CISplatin.
Treatment Medications
CISplatin (PLATINOL) 200 mg in sodium chloride 0.9 % 1,000 mL bag
200 mg (100 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intraperitoneal, ONCE, 1 dose Starting when released
Maximum BSA = 2 m2 (per physician discretion). Warm Intraperitoneal fluid to 37 degrees celsius. Administer as rapidly as possible
by gravity. See intraperitoneal post hydration requirement.
sodium chloride 0.9 % infusion 1,000 mL
at 1,000-2,000 mL/hr, Intraperitoneal, ONCE, 1 dose Starting when released
Infuse 1000mL Intraperitoneal immediately following the end of Intraperitoneal CISplatin infusion. Warm Intraperitoneal fluid to 37
degrees celsius. May slow infusion with patient discomfort. When both Intraperitoneal instillations are complete, instruct the patient
to change position at 15 minute intervals for 2 hours.
Hydration
sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq, magnesium sulfate 2 g infusion
at 330-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse over 2 to 3 hours after completion of IP CISplatin infusion.
Follow-Up
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Zztestonc,Edward E [2435061]
6/6/2017 5:40:12 PM Page 4 of 34
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 1 – Planned for 6/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian (stage III), Primary Peritoneal Carcinoma, Fallopian Tube Cancer (Adjuvant); THERAPY: PACLItaxel 175 mg/m2
IV (over 3 hours) Day 1, CISplatin 75 to 100 mg/m2 intraperitoneal Day 2 and PACLItaxel 60 mg/m2 intraperitoneal Day 8; CYCLE
LENGTH: 21 days; COURSE: 6 cycles.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+6 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+6 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care.
Flush IP access per UWHC guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush intraperitoneal port with 20 mL prior to de-accessing.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, ONCE, 1 dose Starting when released
Flush intraperitoneal port with 10 mL prior to de-accessing.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
lidocaine (LMX) 4% topical dressing kit
Topical, ONCE, 1 dose Starting when released
Please have available when accessing intraperitoneal port. 1 gm per 5cm of skin, topically and covered with occlusive dressing, 60
minutes prior to IP port access.
lidocaine 1 % vial
10 mg, Subcutaneous, ONCE, 1 dose Starting when released
0.5mL-1mL intradermal prior to intraperitoneal port access. (RN to obtain from floorstock.)
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting when released
Give 30 minutes prior to PACLItaxel.
diphenhydramine (BENADRYL) injection 50 mg
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Zztestonc,Edward E [2435061]
6/6/2017 5:40:12 PM Page 5 of 34
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Give 30 minutes prior to PACLItaxel.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Give 30 minutes prior to PACLItaxel.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
sodium chloride 0.9 % infusion 1,750 mL
at 1,000-2,000 mL/hr, Intraperitoneal, ONCE, 1 dose Starting when released
Instill 500mL NS prior to intraperitoneal PACLItaxel and another 500mL of NS concurrently with the PACLItaxel via y-extension.
Instill an additional 750mL NS at the completion of the intraperitoneal PACLItaxel. When all intraperitoneal fluid has been instilled,
instruct the patient to change positions at 15 minute intervals for 2 hours. Warm Intraperitoneal fluids to 37 degrees celsius.
PACLItaxel (TAXOL) 120 mg in dextrose 5 % 250 mL non-PVC bag
120 mg (60 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intraperitoneal, ONCE, 1 dose Starting when released
Maximum BSA = 2 m2 (per physician discretion). Hypersensitivity risk. See emergency meds. Use non-PVC tubing (DO NOT ADD
FILTER TO TUBING). Administer as rapidly as possible via gravity. Warm Intraperitoneal fluids to 37 degrees celsius. Total
intraperitoneal volume to be infused is 2000 mL.
Prepare PACLItaxel by filtering through 0.2 or 0.22 micron filter prior to adding to bag.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15 - Lab Only, Cycle 1 – Planned for 6/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian (stage III), Primary Peritoneal Carcinoma, Fallopian Tube Cancer (Adjuvant); THERAPY: PACLItaxel 175 mg/m2
IV (over 3 hours) Day 1, CISplatin 75 to 100 mg/m2 intraperitoneal Day 2 and PACLItaxel 60 mg/m2 intraperitoneal Day 8; CYCLE
LENGTH: 21 days; COURSE: 6 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,Edward E [2435061]
6/6/2017 5:40:12 PM Page 6 of 34
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Cycle 2 – 6/27/2017 through 7/17/2017 (21 days), Planned
Day 1, Cycle 2 – Planned for 6/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian (stage III), Primary Peritoneal Carcinoma, Fallopian Tube Cancer (Adjuvant); THERAPY: PACLItaxel 175 mg/m2
IV (over 3 hours) Day 1, CISplatin 75 to 100 mg/m2 intraperitoneal Day 2 and PACLItaxel 60 mg/m2 intraperitoneal Day 8; CYCLE
LENGTH: 21 days; COURSE: 6 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+14 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+14 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+14 Approximate, Expires-S+365, Routine
CA 125
Expected-S+14 Approximate, Expires-S+365, Routine
For ovarian, fallopian tube, and primary peritoneal cancer only.
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,500/µL or Platelets less than 100K/µL or Creatinine greater than 2 mg/dL.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 18 mL prior to programming start rate for infusion.
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Zztestonc,Edward E [2435061]
6/6/2017 5:40:12 PM Page 7 of 34
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 350 mg in dextrose 5 % 500 mL non-PVC bag
350 mg (175 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 180 minutes. Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be
treated in a location to optimize emergency care. See Emergency Medications.
** Rush dextrose primed line with 18 mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes. Use non-PVC tubing and 0.2 or 0.22
micron in-line filter during administration.
Take Home Medications
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Zztestonc,Edward E [2435061]
6/6/2017 5:40:12 PM Page 8 of 34
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

dexamethasone (DECADRON) 4 MG tab
Take 2 tabs by mouth 12&6 hours prior to 3rd PACLItaxel IV dose and 2 tabs on Days 3&4 after CISplatin., Disp-24 tab, R-0,
starting S
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: CISplatin (intraperitoneal administration) with pre and post hydration for 510 minutes.
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally); CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel (intraperitoneal administration) for
240 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC, Calcium, Phosphate, Magnesium, CA-
125, Creatinine, Total Bilirubin, Potassium; CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel (IV) for 210 minutes.
Day 2, Cycle 2 – Planned for 6/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian (stage III), Primary Peritoneal Carcinoma, Fallopian Tube Cancer (Adjuvant); THERAPY: PACLItaxel 175 mg/m2
IV (over 3 hours) Day 1, CISplatin 75 to 100 mg/m2 intraperitoneal Day 2 and PACLItaxel 60 mg/m2 intraperitoneal Day 8; CYCLE
LENGTH: 21 days; COURSE: 6 cycles.
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.
Flush IP access per UWHC guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush intraperitoneal port with 20 mL prior to de-accessing.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, ONCE, 1 dose Starting when released
Flush intraperitoneal port with 10 mL prior to de-accessing.
Hydration
sodium chloride 0.9 % infusion 2,000 mL
at 1,000 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 2000 mL over 2 hours prior to CISplatin IP instillation.
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
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Zztestonc,Edward E [2435061]
6/6/2017 5:40:12 PM Page 9 of 34
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

12 mg, Oral, ONCE, 1 dose Starting when released
lidocaine (LMX) 4% topical dressing kit
Topical, ONCE, 1 dose Starting when released
Please have available when accessing intraperitoneal port. 1 gm per 5cm of skin, topically and covered with occlusive dressing, 60
minutes prior to IP port access.
lidocaine 1 % vial
10 mg, Subcutaneous, ONCE, 1 dose Starting when released
0.5mL-1mL intradermal prior to intraperitoneal port access. (RN to obtain from floorstock.)
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting when released
IV push rate 10 mg/minute. Give 30 minutes prior to CISplatin.
Treatment Medications
CISplatin (PLATINOL) 200 mg in sodium chloride 0.9 % 1,000 mL bag
200 mg (100 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intraperitoneal, ONCE, 1 dose Starting when released
Maximum BSA = 2 m2 (per physician discretion). Warm Intraperitoneal fluid to 37 degrees celsius. Administer as rapidly as possible
by gravity. See intraperitoneal post hydration requirement.
sodium chloride 0.9 % infusion 1,000 mL
at 1,000-2,000 mL/hr, Intraperitoneal, ONCE, 1 dose Starting when released
Infuse 1000mL Intraperitoneal immediately following the end of Intraperitoneal CISplatin infusion. Warm Intraperitoneal fluid to 37
degrees celsius. May slow infusion with patient discomfort. When both Intraperitoneal instillations are complete, instruct the patient
to change position at 15 minute intervals for 2 hours.
Hydration
sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq, magnesium sulfate 2 g infusion
at 330-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse over 2 to 3 hours after completion of IP CISplatin infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 2 – Planned for 7/4/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian (stage III), Primary Peritoneal Carcinoma, Fallopian Tube Cancer (Adjuvant); THERAPY: PACLItaxel 175 mg/m2
IV (over 3 hours) Day 1, CISplatin 75 to 100 mg/m2 intraperitoneal Day 2 and PACLItaxel 60 mg/m2 intraperitoneal Day 8; CYCLE
LENGTH: 21 days; COURSE: 6 cycles.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+6 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+6 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care.
Flush IP access per UWHC guidelines
Order details
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Zztestonc,Edward E [2435061]
6/6/2017 5:40:12 PM Page 10 of 34
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush intraperitoneal port with 20 mL prior to de-accessing.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, ONCE, 1 dose Starting when released
Flush intraperitoneal port with 10 mL prior to de-accessing.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
lidocaine (LMX) 4% topical dressing kit
Topical, ONCE, 1 dose Starting when released
Please have available when accessing intraperitoneal port. 1 gm per 5cm of skin, topically and covered with occlusive dressing, 60
minutes prior to IP port access.
lidocaine 1 % vial
10 mg, Subcutaneous, ONCE, 1 dose Starting when released
0.5mL-1mL intradermal prior to intraperitoneal port access. (RN to obtain from floorstock.)
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Give 30 minutes prior to PACLItaxel.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Give 30 minutes prior to PACLItaxel.
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting when released
Give 30 minutes prior to PACLItaxel.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
sodium chloride 0.9 % infusion 1,750 mL
at 1,000-2,000 mL/hr, Intraperitoneal, ONCE, 1 dose Starting when released
Instill 500mL NS prior to intraperitoneal PACLItaxel and another 500mL of NS concurrently with the PACLItaxel via y-extension.
Instill an additional 750mL NS at the completion of the intraperitoneal PACLItaxel. When all intraperitoneal fluid has been instilled,
instruct the patient to change positions at 15 minute intervals for 2 hours. Warm Intraperitoneal fluids to 37 degrees celsius.
PACLItaxel (TAXOL) 120 mg in dextrose 5 % 250 mL non-PVC bag
120 mg (60 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intraperitoneal, ONCE, 1 dose Starting when released
Maximum BSA = 2 m2 (per physician discretion). Hypersensitivity risk. See emergency meds. Use non-PVC tubing (DO NOT ADD
FILTER TO TUBING). Administer as rapidly as possible via gravity. Warm Intraperitoneal fluids to 37 degrees celsius. Total
intraperitoneal volume to be infused is 2000 mL.
Prepare PACLItaxel by filtering through 0.2 or 0.22 micron filter prior to adding to bag.
Follow-Up
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Zztestonc,Edward E [2435061]
6/6/2017 5:40:12 PM Page 11 of 34
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15 - Lab Only, Cycle 2 – Planned for 7/11/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian (stage III), Primary Peritoneal Carcinoma, Fallopian Tube Cancer (Adjuvant); THERAPY: PACLItaxel 175 mg/m2
IV (over 3 hours) Day 1, CISplatin 75 to 100 mg/m2 intraperitoneal Day 2 and PACLItaxel 60 mg/m2 intraperitoneal Day 8; CYCLE
LENGTH: 21 days; COURSE: 6 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 – 7/18/2017 through 8/7/2017 (21 days), Planned
Day 1, Cycle 3 – Planned for 7/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian (stage III), Primary Peritoneal Carcinoma, Fallopian Tube Cancer (Adjuvant); THERAPY: PACLItaxel 175 mg/m2
IV (over 3 hours) Day 1, CISplatin 75 to 100 mg/m2 intraperitoneal Day 2 and PACLItaxel 60 mg/m2 intraperitoneal Day 8; CYCLE
LENGTH: 21 days; COURSE: 6 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+14 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+14 Approximate, Expires-S+365, Routine
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Zztestonc,Edward E [2435061]
6/6/2017 5:40:12 PM Page 12 of 34
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

MAGNESIUM
Expected-S+14 Approximate, Expires-S+365, Routine
CA 125
Expected-S+14 Approximate, Expires-S+365, Routine
For ovarian, fallopian tube, and primary peritoneal cancer only.
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,500/µL or Platelets less than 100K/µL or Creatinine greater than 2 mg/dL.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 18 mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
diphenhydramine (BENADRYL) injection 50 mg
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Zztestonc,Edward E [2435061]
6/6/2017 5:40:12 PM Page 13 of 34
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 350 mg in dextrose 5 % 500 mL non-PVC bag
350 mg (175 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 180 minutes. Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be
treated in a location to optimize emergency care. See Emergency Medications.
** Rush dextrose primed line with 18 mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes. Use non-PVC tubing and 0.2 or 0.22
micron in-line filter during administration.
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: CISplatin (intraperitoneal administration) with pre and post hydration for 510 minutes.
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally); CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel (intraperitoneal administration) for
240 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC, Calcium, Phosphate, Magnesium, CA-
125, Creatinine, Total Bilirubin, Potassium; CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel (IV) for 210 minutes.
Day 2, Cycle 3 – Planned for 7/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian (stage III), Primary Peritoneal Carcinoma, Fallopian Tube Cancer (Adjuvant); THERAPY: PACLItaxel 175 mg/m2
IV (over 3 hours) Day 1, CISplatin 75 to 100 mg/m2 intraperitoneal Day 2 and PACLItaxel 60 mg/m2 intraperitoneal Day 8; CYCLE
LENGTH: 21 days; COURSE: 6 cycles.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
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Zztestonc,Edward E [2435061]
6/6/2017 5:40:12 PM Page 14 of 34
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Flush IP access per UWHC guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush intraperitoneal port with 20 mL prior to de-accessing.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, ONCE, 1 dose Starting when released
Flush intraperitoneal port with 10 mL prior to de-accessing.
Hydration
sodium chloride 0.9 % infusion 2,000 mL
at 1,000 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 2000 mL over 2 hours prior to CISplatin IP instillation.
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
lidocaine (LMX) 4% topical dressing kit
Topical, ONCE, 1 dose Starting when released
Please have available when accessing intraperitoneal port. 1 gm per 5cm of skin, topically and covered with occlusive dressing, 60
minutes prior to IP port access.
lidocaine 1 % vial
10 mg, Subcutaneous, ONCE, 1 dose Starting when released
0.5mL-1mL intradermal prior to intraperitoneal port access. (RN to obtain from floorstock.)
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting when released
IV push rate 10 mg/minute. Give 30 minutes prior to CISplatin.
Treatment Medications
CISplatin (PLATINOL) 200 mg in sodium chloride 0.9 % 1,000 mL bag
200 mg (100 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intraperitoneal, ONCE, 1 dose Starting when released
Maximum BSA = 2 m2 (per physician discretion). Warm Intraperitoneal fluid to 37 degrees celsius. Administer as rapidly as possible
by gravity. See intraperitoneal post hydration requirement.
sodium chloride 0.9 % infusion 1,000 mL
at 1,000-2,000 mL/hr, Intraperitoneal, ONCE, 1 dose Starting when released
Infuse 1000mL Intraperitoneal immediately following the end of Intraperitoneal CISplatin infusion. Warm Intraperitoneal fluid to 37
degrees celsius. May slow infusion with patient discomfort. When both Intraperitoneal instillations are complete, instruct the patient
to change position at 15 minute intervals for 2 hours.
Hydration
sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq, magnesium sulfate 2 g infusion
at 330-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse over 2 to 3 hours after completion of IP CISplatin infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 3 – Planned for 7/25/2017
Treatment Plan Information
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Zztestonc,Edward E [2435061]
6/6/2017 5:40:12 PM Page 15 of 34
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Ovarian (stage III), Primary Peritoneal Carcinoma, Fallopian Tube Cancer (Adjuvant); THERAPY:
PACLItaxel 175 mg/m2 IV (over 3 hours) Day 1, CISplatin 75 to 100 mg/m2 intraperitoneal Day 2 and PACLItaxel
60 mg/m2 intraperitoneal Day 8; CYCLE LENGTH: 21 days; COURSE: 6 cycles.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+6 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+6 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care.
Flush IP access per UWHC guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush intraperitoneal port with 20 mL prior to de-accessing.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, ONCE, 1 dose Starting when released
Flush intraperitoneal port with 10 mL prior to de-accessing.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
lidocaine (LMX) 4% topical dressing kit
Topical, ONCE, 1 dose Starting when released
Please have available when accessing intraperitoneal port. 1 gm per 5cm of skin, topically and covered with occlusive dressing, 60
minutes prior to IP port access.
lidocaine 1 % vial
10 mg, Subcutaneous, ONCE, 1 dose Starting when released
0.5mL-1mL intradermal prior to intraperitoneal port access. (RN to obtain from floorstock.)
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Give 30 minutes prior to PACLItaxel.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Give 30 minutes prior to PACLItaxel.
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting when released
Give 30 minutes prior to PACLItaxel.
Emergency Medications
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Zztestonc,Edward E [2435061]
6/6/2017 5:40:12 PM Page 16 of 34
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
sodium chloride 0.9 % infusion 1,750 mL
at 1,000-2,000 mL/hr, Intraperitoneal, ONCE, 1 dose Starting when released
Instill 500mL NS prior to intraperitoneal PACLItaxel and another 500mL of NS concurrently with the PACLItaxel via y-extension.
Instill an additional 750mL NS at the completion of the intraperitoneal PACLItaxel. When all intraperitoneal fluid has been instilled,
instruct the patient to change positions at 15 minute intervals for 2 hours. Warm Intraperitoneal fluids to 37 degrees celsius.
PACLItaxel (TAXOL) 120 mg in dextrose 5 % 250 mL non-PVC bag
120 mg (60 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intraperitoneal, ONCE, 1 dose Starting when released
Maximum BSA = 2 m2 (per physician discretion). Hypersensitivity risk. See emergency meds. Use non-PVC tubing (DO NOT ADD
FILTER TO TUBING). Administer as rapidly as possible via gravity. Warm Intraperitoneal fluids to 37 degrees celsius. Total
intraperitoneal volume to be infused is 2000 mL.
Prepare PACLItaxel by filtering through 0.2 or 0.22 micron filter prior to adding to bag.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15 - Lab Only, Cycle 3 – Planned for 8/1/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian (stage III), Primary Peritoneal Carcinoma, Fallopian Tube Cancer (Adjuvant); THERAPY: PACLItaxel 175 mg/m2
IV (over 3 hours) Day 1, CISplatin 75 to 100 mg/m2 intraperitoneal Day 2 and PACLItaxel 60 mg/m2 intraperitoneal Day 8; CYCLE
LENGTH: 21 days; COURSE: 6 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 – 8/8/2017 through 8/28/2017 (21 days), Planned
Day 1, Cycle 4 – Planned for 8/8/2017
Treatment Plan Information
Treatment Plan Summary
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Zztestonc,Edward E [2435061]
6/6/2017 5:40:12 PM Page 17 of 34
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

DISEASE: Ovarian (stage III), Primary Peritoneal Carcinoma, Fallopian Tube Cancer (Adjuvant); THERAPY:
PACLItaxel 175 mg/m2 IV (over 3 hours) Day 1, CISplatin 75 to 100 mg/m2 intraperitoneal Day 2 and PACLItaxel
60 mg/m2 intraperitoneal Day 8; CYCLE LENGTH: 21 days; COURSE: 6 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+14 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+14 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+14 Approximate, Expires-S+365, Routine
CA 125
Expected-S+14 Approximate, Expires-S+365, Routine
For ovarian, fallopian tube, and primary peritoneal cancer only.
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,500/µL or Platelets less than 100K/µL or Creatinine greater than 2 mg/dL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 18 mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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Zztestonc,Edward E [2435061]
6/6/2017 5:40:12 PM Page 18 of 34
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 350 mg in dextrose 5 % 500 mL non-PVC bag
350 mg (175 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 180 minutes. Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be
treated in a location to optimize emergency care. See Emergency Medications.
** Rush dextrose primed line with 18 mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes. Use non-PVC tubing and 0.2 or 0.22
micron in-line filter during administration.
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: CISplatin (intraperitoneal administration) with pre and post hydration for 510 minutes.
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally); CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel (intraperitoneal administration) for
240 minutes.
DAY 15 FOLLOW-UP
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Zztestonc,Edward E [2435061]
6/6/2017 5:40:12 PM Page 19 of 34
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

LABS: CBC, ANC (DIFF if done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC, Calcium, Phosphate, Magnesium, CA-
125, Creatinine, Total Bilirubin, Potassium; CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel (IV) for 210 minutes.
Day 2, Cycle 4 – Planned for 8/9/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian (stage III), Primary Peritoneal Carcinoma, Fallopian Tube Cancer (Adjuvant); THERAPY: PACLItaxel 175 mg/m2
IV (over 3 hours) Day 1, CISplatin 75 to 100 mg/m2 intraperitoneal Day 2 and PACLItaxel 60 mg/m2 intraperitoneal Day 8; CYCLE
LENGTH: 21 days; COURSE: 6 cycles.
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.
Flush IP access per UWHC guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush intraperitoneal port with 20 mL prior to de-accessing.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, ONCE, 1 dose Starting when released
Flush intraperitoneal port with 10 mL prior to de-accessing.
Hydration
sodium chloride 0.9 % infusion 2,000 mL
at 1,000 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 2000 mL over 2 hours prior to CISplatin IP instillation.
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
lidocaine (LMX) 4% topical dressing kit
Topical, ONCE, 1 dose Starting when released
Please have available when accessing intraperitoneal port. 1 gm per 5cm of skin, topically and covered with occlusive dressing, 60
minutes prior to IP port access.
lidocaine 1 % vial
10 mg, Subcutaneous, ONCE, 1 dose Starting when released
0.5mL-1mL intradermal prior to intraperitoneal port access. (RN to obtain from floorstock.)
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting when released
IV push rate 10 mg/minute. Give 30 minutes prior to CISplatin.
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Zztestonc,Edward E [2435061]
6/6/2017 5:40:12 PM Page 20 of 34
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Treatment Medications
CISplatin (PLATINOL) 200 mg in sodium chloride 0.9 % 1,000 mL bag
200 mg (100 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intraperitoneal, ONCE, 1 dose Starting when released
Maximum BSA = 2 m2 (per physician discretion). Warm Intraperitoneal fluid to 37 degrees celsius. Administer as rapidly as possible
by gravity. See intraperitoneal post hydration requirement.
sodium chloride 0.9 % infusion 1,000 mL
at 1,000-2,000 mL/hr, Intraperitoneal, ONCE, 1 dose Starting when released
Infuse 1000mL Intraperitoneal immediately following the end of Intraperitoneal CISplatin infusion. Warm Intraperitoneal fluid to 37
degrees celsius. May slow infusion with patient discomfort. When both Intraperitoneal instillations are complete, instruct the patient
to change position at 15 minute intervals for 2 hours.
Hydration
sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq, magnesium sulfate 2 g infusion
at 330-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse over 2 to 3 hours after completion of IP CISplatin infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 4 – Planned for 8/15/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian (stage III), Primary Peritoneal Carcinoma, Fallopian Tube Cancer (Adjuvant); THERAPY: PACLItaxel 175 mg/m2
IV (over 3 hours) Day 1, CISplatin 75 to 100 mg/m2 intraperitoneal Day 2 and PACLItaxel 60 mg/m2 intraperitoneal Day 8; CYCLE
LENGTH: 21 days; COURSE: 6 cycles.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+6 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+6 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care.
Flush IP access per UWHC guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush intraperitoneal port with 20 mL prior to de-accessing.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, ONCE, 1 dose Starting when released
Flush intraperitoneal port with 10 mL prior to de-accessing.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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Zztestonc,Edward E [2435061]
6/6/2017 5:40:12 PM Page 21 of 34
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 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
lidocaine (LMX) 4% topical dressing kit
Topical, ONCE, 1 dose Starting when released
Please have available when accessing intraperitoneal port. 1 gm per 5cm of skin, topically and covered with occlusive dressing, 60
minutes prior to IP port access.
lidocaine 1 % vial
10 mg, Subcutaneous, ONCE, 1 dose Starting when released
0.5mL-1mL intradermal prior to intraperitoneal port access. (RN to obtain from floorstock.)
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Give 30 minutes prior to PACLItaxel.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Give 30 minutes prior to PACLItaxel.
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting when released
Give 30 minutes prior to PACLItaxel.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
sodium chloride 0.9 % infusion 1,750 mL
at 1,000-2,000 mL/hr, Intraperitoneal, ONCE, 1 dose Starting when released
Instill 500mL NS prior to intraperitoneal PACLItaxel and another 500mL of NS concurrently with the PACLItaxel via y-extension.
Instill an additional 750mL NS at the completion of the intraperitoneal PACLItaxel. When all intraperitoneal fluid has been instilled,
instruct the patient to change positions at 15 minute intervals for 2 hours. Warm Intraperitoneal fluids to 37 degrees celsius.
PACLItaxel (TAXOL) 120 mg in dextrose 5 % 250 mL non-PVC bag
120 mg (60 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intraperitoneal, ONCE, 1 dose Starting when released
Maximum BSA = 2 m2 (per physician discretion). Hypersensitivity risk. See emergency meds. Use non-PVC tubing (DO NOT ADD
FILTER TO TUBING). Administer as rapidly as possible via gravity. Warm Intraperitoneal fluids to 37 degrees celsius. Total
intraperitoneal volume to be infused is 2000 mL.
Prepare PACLItaxel by filtering through 0.2 or 0.22 micron filter prior to adding to bag.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15 - Lab Only, Cycle 4 – Planned for 8/22/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian (stage III), Primary Peritoneal Carcinoma, Fallopian Tube Cancer (Adjuvant); THERAPY: PACLItaxel 175 mg/m2
IV (over 3 hours) Day 1, CISplatin 75 to 100 mg/m2 intraperitoneal Day 2 and PACLItaxel 60 mg/m2 intraperitoneal Day 8; CYCLE
LENGTH: 21 days; COURSE: 6 cycles.
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Zztestonc,Edward E [2435061]
6/6/2017 5:40:12 PM Page 22 of 34
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 – 8/29/2017 through 9/18/2017 (21 days), Planned
Day 1, Cycle 5 – Planned for 8/29/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian (stage III), Primary Peritoneal Carcinoma, Fallopian Tube Cancer (Adjuvant); THERAPY: PACLItaxel 175 mg/m2
IV (over 3 hours) Day 1, CISplatin 75 to 100 mg/m2 intraperitoneal Day 2 and PACLItaxel 60 mg/m2 intraperitoneal Day 8; CYCLE
LENGTH: 21 days; COURSE: 6 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+14 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+14 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+14 Approximate, Expires-S+365, Routine
CA 125
Expected-S+14 Approximate, Expires-S+365, Routine
For ovarian, fallopian tube, and primary peritoneal cancer only.
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
POTASSIUM
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Zztestonc,Edward E [2435061]
6/6/2017 5:40:12 PM Page 23 of 34
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,500/µL or Platelets less than 100K/µL or Creatinine greater than 2 mg/dL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 18 mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
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Zztestonc,Edward E [2435061]
6/6/2017 5:40:12 PM Page 24 of 34
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 350 mg in dextrose 5 % 500 mL non-PVC bag
350 mg (175 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 180 minutes. Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be
treated in a location to optimize emergency care. See Emergency Medications.
** Rush dextrose primed line with 18 mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes. Use non-PVC tubing and 0.2 or 0.22
micron in-line filter during administration.
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: CISplatin (intraperitoneal administration) with pre and post hydration for 510 minutes.
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally); CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel (intraperitoneal administration) for
240 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC, Calcium, Phosphate, Magnesium, CA-
125, Creatinine, Total Bilirubin, Potassium; CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel (IV) for 210 minutes.
Day 2, Cycle 5 – Planned for 8/30/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian (stage III), Primary Peritoneal Carcinoma, Fallopian Tube Cancer (Adjuvant); THERAPY: PACLItaxel 175 mg/m2
IV (over 3 hours) Day 1, CISplatin 75 to 100 mg/m2 intraperitoneal Day 2 and PACLItaxel 60 mg/m2 intraperitoneal Day 8; CYCLE
LENGTH: 21 days; COURSE: 6 cycles.
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.
Flush IP access per UWHC guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush intraperitoneal port with 20 mL prior to de-accessing.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, ONCE, 1 dose Starting when released
Flush intraperitoneal port with 10 mL prior to de-accessing.
Hydration
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Zztestonc,Edward E [2435061]
6/6/2017 5:40:12 PM Page 25 of 34
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 2,000 mL
at 1,000 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 2000 mL over 2 hours prior to CISplatin IP instillation.
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
lidocaine (LMX) 4% topical dressing kit
Topical, ONCE, 1 dose Starting when released
Please have available when accessing intraperitoneal port. 1 gm per 5cm of skin, topically and covered with occlusive dressing, 60
minutes prior to IP port access.
lidocaine 1 % vial
10 mg, Subcutaneous, ONCE, 1 dose Starting when released
0.5mL-1mL intradermal prior to intraperitoneal port access. (RN to obtain from floorstock.)
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting when released
IV push rate 10 mg/minute. Give 30 minutes prior to CISplatin.
Treatment Medications
CISplatin (PLATINOL) 200 mg in sodium chloride 0.9 % 1,000 mL bag
200 mg (100 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intraperitoneal, ONCE, 1 dose Starting when released
Maximum BSA = 2 m2 (per physician discretion). Warm Intraperitoneal fluid to 37 degrees celsius. Administer as rapidly as possible
by gravity. See intraperitoneal post hydration requirement.
sodium chloride 0.9 % infusion 1,000 mL
at 1,000-2,000 mL/hr, Intraperitoneal, ONCE, 1 dose Starting when released
Infuse 1000mL Intraperitoneal immediately following the end of Intraperitoneal CISplatin infusion. Warm Intraperitoneal fluid to 37
degrees celsius. May slow infusion with patient discomfort. When both Intraperitoneal instillations are complete, instruct the patient
to change position at 15 minute intervals for 2 hours.
Hydration
sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq, magnesium sulfate 2 g infusion
at 330-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse over 2 to 3 hours after completion of IP CISplatin infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 5 – Planned for 9/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian (stage III), Primary Peritoneal Carcinoma, Fallopian Tube Cancer (Adjuvant); THERAPY: PACLItaxel 175 mg/m2
IV (over 3 hours) Day 1, CISplatin 75 to 100 mg/m2 intraperitoneal Day 2 and PACLItaxel 60 mg/m2 intraperitoneal Day 8; CYCLE
LENGTH: 21 days; COURSE: 6 cycles.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+6 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+6 Approximate, Expires-S+365, Routine
Treatment Conditions
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Zztestonc,Edward E [2435061]
6/6/2017 5:40:12 PM Page 26 of 34
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care.
Flush IP access per UWHC guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush intraperitoneal port with 20 mL prior to de-accessing.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, ONCE, 1 dose Starting when released
Flush intraperitoneal port with 10 mL prior to de-accessing.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
lidocaine (LMX) 4% topical dressing kit
Topical, ONCE, 1 dose Starting when released
Please have available when accessing intraperitoneal port. 1 gm per 5cm of skin, topically and covered with occlusive dressing, 60
minutes prior to IP port access.
lidocaine 1 % vial
10 mg, Subcutaneous, ONCE, 1 dose Starting when released
0.5mL-1mL intradermal prior to intraperitoneal port access. (RN to obtain from floorstock.)
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Give 30 minutes prior to PACLItaxel.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Give 30 minutes prior to PACLItaxel.
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting when released
Give 30 minutes prior to PACLItaxel.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
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Zztestonc,Edward E [2435061]
6/6/2017 5:40:12 PM Page 27 of 34
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Treatment Medications
sodium chloride 0.9 % infusion 1,750 mL
at 1,000-2,000 mL/hr, Intraperitoneal, ONCE, 1 dose Starting when released
Instill 500mL NS prior to intraperitoneal PACLItaxel and another 500mL of NS concurrently with the PACLItaxel via y-extension.
Instill an additional 750mL NS at the completion of the intraperitoneal PACLItaxel. When all intraperitoneal fluid has been instilled,
instruct the patient to change positions at 15 minute intervals for 2 hours. Warm Intraperitoneal fluids to 37 degrees celsius.
PACLItaxel (TAXOL) 120 mg in dextrose 5 % 250 mL non-PVC bag
120 mg (60 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intraperitoneal, ONCE, 1 dose Starting when released
Maximum BSA = 2 m2 (per physician discretion). Hypersensitivity risk. See emergency meds. Use non-PVC tubing (DO NOT ADD
FILTER TO TUBING). Administer as rapidly as possible via gravity. Warm Intraperitoneal fluids to 37 degrees celsius. Total
intraperitoneal volume to be infused is 2000 mL.
Prepare PACLItaxel by filtering through 0.2 or 0.22 micron filter prior to adding to bag.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15 - Lab Only, Cycle 5 – Planned for 9/12/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian (stage III), Primary Peritoneal Carcinoma, Fallopian Tube Cancer (Adjuvant); THERAPY: PACLItaxel 175 mg/m2
IV (over 3 hours) Day 1, CISplatin 75 to 100 mg/m2 intraperitoneal Day 2 and PACLItaxel 60 mg/m2 intraperitoneal Day 8; CYCLE
LENGTH: 21 days; COURSE: 6 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 6 – 9/19/2017 through 10/9/2017 (21 days), Planned
Day 1, Cycle 6 – Planned for 9/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian (stage III), Primary Peritoneal Carcinoma, Fallopian Tube Cancer (Adjuvant); THERAPY: PACLItaxel 175 mg/m2
IV (over 3 hours) Day 1, CISplatin 75 to 100 mg/m2 intraperitoneal Day 2 and PACLItaxel 60 mg/m2 intraperitoneal Day 8; CYCLE
LENGTH: 21 days; COURSE: 6 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
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Zztestonc,Edward E [2435061]
6/6/2017 5:40:12 PM Page 28 of 34
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+14 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+14 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+14 Approximate, Expires-S+365, Routine
CA 125
Expected-S+14 Approximate, Expires-S+365, Routine
For ovarian, fallopian tube, and primary peritoneal cancer only.
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,500/µL or Platelets less than 100K/µL or Creatinine greater than 2 mg/dL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 18 mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
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Zztestonc,Edward E [2435061]
6/6/2017 5:40:12 PM Page 29 of 34
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 350 mg in dextrose 5 % 500 mL non-PVC bag
350 mg (175 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 180 minutes. Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be
treated in a location to optimize emergency care. See Emergency Medications.
** Rush dextrose primed line with 18 mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes. Use non-PVC tubing and 0.2 or 0.22
micron in-line filter during administration.
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: CISplatin (intraperitoneal administration) with pre and post hydration for 510 minutes.
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally); CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel (intraperitoneal administration) for
240 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC, Calcium, Phosphate, Magnesium, CA-
125, Creatinine, Total Bilirubin, Potassium; CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel (IV) for 210 minutes.
Day 2, Cycle 6 – Planned for 9/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian (stage III), Primary Peritoneal Carcinoma, Fallopian Tube Cancer (Adjuvant); THERAPY: PACLItaxel 175 mg/m2
IV (over 3 hours) Day 1, CISplatin 75 to 100 mg/m2 intraperitoneal Day 2 and PACLItaxel 60 mg/m2 intraperitoneal Day 8; CYCLE
LENGTH: 21 days; COURSE: 6 cycles.
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Zztestonc,Edward E [2435061]
6/6/2017 5:40:12 PM Page 30 of 34
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Flush IP access per UWHC guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush intraperitoneal port with 20 mL prior to de-accessing.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, ONCE, 1 dose Starting when released
Flush intraperitoneal port with 10 mL prior to de-accessing.
Hydration
sodium chloride 0.9 % infusion 2,000 mL
at 1,000 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 2000 mL over 2 hours prior to CISplatin IP instillation.
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
lidocaine (LMX) 4% topical dressing kit
Topical, ONCE, 1 dose Starting when released
Please have available when accessing intraperitoneal port. 1 gm per 5cm of skin, topically and covered with occlusive dressing, 60
minutes prior to IP port access.
lidocaine 1 % vial
10 mg, Subcutaneous, ONCE, 1 dose Starting when released
0.5mL-1mL intradermal prior to intraperitoneal port access. (RN to obtain from floorstock.)
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting when released
IV push rate 10 mg/minute. Give 30 minutes prior to CISplatin.
Treatment Medications
CISplatin (PLATINOL) 200 mg in sodium chloride 0.9 % 1,000 mL bag
200 mg (100 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intraperitoneal, ONCE, 1 dose Starting when released
Maximum BSA = 2 m2 (per physician discretion). Warm Intraperitoneal fluid to 37 degrees celsius. Administer as rapidly as possible
by gravity. See intraperitoneal post hydration requirement.
sodium chloride 0.9 % infusion 1,000 mL
at 1,000-2,000 mL/hr, Intraperitoneal, ONCE, 1 dose Starting when released
Infuse 1000mL Intraperitoneal immediately following the end of Intraperitoneal CISplatin infusion. Warm Intraperitoneal fluid to 37
degrees celsius. May slow infusion with patient discomfort. When both Intraperitoneal instillations are complete, instruct the patient
to change position at 15 minute intervals for 2 hours.
Hydration
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Zztestonc,Edward E [2435061]
6/6/2017 5:40:12 PM Page 31 of 34
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 % 1,000 mL with potassium chloride 20 mEq, magnesium sulfate 2 g infusion
at 330-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse over 2 to 3 hours after completion of IP CISplatin infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 6 – Planned for 9/26/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian (stage III), Primary Peritoneal Carcinoma, Fallopian Tube Cancer (Adjuvant); THERAPY: PACLItaxel 175 mg/m2
IV (over 3 hours) Day 1, CISplatin 75 to 100 mg/m2 intraperitoneal Day 2 and PACLItaxel 60 mg/m2 intraperitoneal Day 8; CYCLE
LENGTH: 21 days; COURSE: 6 cycles.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+6 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+6 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care.
Flush IP access per UWHC guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush intraperitoneal port with 20 mL prior to de-accessing.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, ONCE, 1 dose Starting when released
Flush intraperitoneal port with 10 mL prior to de-accessing.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
lidocaine (LMX) 4% topical dressing kit
Topical, ONCE, 1 dose Starting when released
Please have available when accessing intraperitoneal port. 1 gm per 5cm of skin, topically and covered with occlusive dressing, 60
minutes prior to IP port access.
lidocaine 1 % vial
10 mg, Subcutaneous, ONCE, 1 dose Starting when released
0.5mL-1mL intradermal prior to intraperitoneal port access. (RN to obtain from floorstock.)
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Zztestonc,Edward E [2435061]
6/6/2017 5:40:12 PM Page 32 of 34
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Give 30 minutes prior to PACLItaxel.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Give 30 minutes prior to PACLItaxel.
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting when released
Give 30 minutes prior to PACLItaxel.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
sodium chloride 0.9 % infusion 1,750 mL
at 1,000-2,000 mL/hr, Intraperitoneal, ONCE, 1 dose Starting when released
Instill 500mL NS prior to intraperitoneal PACLItaxel and another 500mL of NS concurrently with the PACLItaxel via y-extension.
Instill an additional 750mL NS at the completion of the intraperitoneal PACLItaxel. When all intraperitoneal fluid has been instilled,
instruct the patient to change positions at 15 minute intervals for 2 hours. Warm Intraperitoneal fluids to 37 degrees celsius.
PACLItaxel (TAXOL) 120 mg in dextrose 5 % 250 mL non-PVC bag
120 mg (60 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intraperitoneal, ONCE, 1 dose Starting when released
Maximum BSA = 2 m2 (per physician discretion). Hypersensitivity risk. See emergency meds. Use non-PVC tubing (DO NOT ADD
FILTER TO TUBING). Administer as rapidly as possible via gravity. Warm Intraperitoneal fluids to 37 degrees celsius. Total
intraperitoneal volume to be infused is 2000 mL.
Prepare PACLItaxel by filtering through 0.2 or 0.22 micron filter prior to adding to bag.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15 - Lab Only, Cycle 6 – Planned for 10/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian (stage III), Primary Peritoneal Carcinoma, Fallopian Tube Cancer (Adjuvant); THERAPY: PACLItaxel 175 mg/m2
IV (over 3 hours) Day 1, CISplatin 75 to 100 mg/m2 intraperitoneal Day 2 and PACLItaxel 60 mg/m2 intraperitoneal Day 8; CYCLE
LENGTH: 21 days; COURSE: 6 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
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Zztestonc,Edward E [2435061]
6/6/2017 5:40:12 PM Page 33 of 34
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,Edward E [2435061]
6/6/2017 5:40:12 PM Page 34 of 34
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org