/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/beacon-protocols/,/clinical/cckm-tools/content/beacon-protocols/gyn/,

/clinical/cckm-tools/content/beacon-protocols/gyn/name-96769-en.cckm

201706157

page

100

UWHC,UWMF,

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

CSC GYN Methotrexate(14D1-5) VER 1-11-17 (HL 4586)

CSC GYN Methotrexate(14D1-5) VER 1-11-17 (HL 4586) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GYN


CSC GYN METHOTREXATE (14D:1-5) 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: Gestational Trophoblastic Neoplasia (Adjuvant/ Advanced); THERAPY: methotrexate 0.4 mg/kg IV Day 1,2,3,4, and 5;
CYCLE LENGTH: 14 days; COURSE: continue for 1 to 2 cycles past the first normal hCG level.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
HCG, QUANTITATIVE
Expected-S Approximate, Expires-S+365, Routine
PROTEIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, DIRECT
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S Approximate, Expires-S+365, Routine
Take Home Medications
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed., 8 mg, Disp-20 tab, R-5, EVERY 8 HOURS PRN starting S, Local Printer
Cycle 1 – 6/6/2017 through 6/19/2017 (14 days), Planned
Day 1, Cycle 1 – Planned for 6/6/2017
Treatment Plan Information
Reference Information (1)
GESTATIONAL TROPHOBLASTIC NEOPLASIA: Lurain J, et al. Am J Obstet Gynecol 1995;172:574-9
Treatment Plan Summary
DISEASE: Gestational Trophoblastic Neoplasia (Adjuvant/ Advanced); THERAPY: methotrexate 0.4 mg/kg IV Day 1,2,3,4, and 5;
CYCLE LENGTH: 14 days; COURSE: continue for 1 to 2 cycles past the first normal hCG level.
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Zztestonc,Edward E [2435061]
6/6/2017 6:24:44 PM Page 1 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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: ANC (DIFF if to be done locally), Platelets, Hemoglobin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,500/µL or Platelets less than 100K/µL, or Hemoglobin less than 8 g/dL.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
methotrexate PF 32 mg in sodium chloride 0.9 % 10 mL injection
32 mg (rounded from 31.76 mg = 0.4 mg/kg × 79.4 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Push over 2 to 5 minutes.
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: methotrexate for 30 minutes.
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: methotrexate for 30 minutes.
DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: methotrexate for 30 minutes.
DAY 5 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: methotrexate for 30 minutes.
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 15 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Creatinine, Beta HCG, Total Protein, Albumin, Direct Bilirubin, Total Bilirubin, AST, ALT, Alkaline Phosphatase;
CHEMOTHERAPY ROOM APPOINTMENT: methotrexate for 30 minutes.
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Zztestonc,Edward E [2435061]
6/6/2017 6:24:44 PM Page 2 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Day 2, Cycle 1 – Planned for 6/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gestational Trophoblastic Neoplasia (Adjuvant/ Advanced); THERAPY: methotrexate 0.4 mg/kg IV Day 1,2,3,4, and 5;
CYCLE LENGTH: 14 days; COURSE: continue for 1 to 2 cycles past the first normal hCG level.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
methotrexate PF 32 mg in sodium chloride 0.9 % 10 mL injection
32 mg (rounded from 31.76 mg = 0.4 mg/kg × 79.4 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Push over 2 to 5 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 1 – Planned for 6/8/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gestational Trophoblastic Neoplasia (Adjuvant/ Advanced); THERAPY: methotrexate 0.4 mg/kg IV Day 1,2,3,4, and 5;
CYCLE LENGTH: 14 days; COURSE: continue for 1 to 2 cycles past the first normal hCG level.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
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 6:24:44 PM Page 3 of 29
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.
Treatment Medications
methotrexate PF 32 mg in sodium chloride 0.9 % 10 mL injection
32 mg (rounded from 31.76 mg = 0.4 mg/kg × 79.4 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Push over 2 to 5 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 4, Cycle 1 – Planned for 6/9/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gestational Trophoblastic Neoplasia (Adjuvant/ Advanced); THERAPY: methotrexate 0.4 mg/kg IV Day 1,2,3,4, and 5;
CYCLE LENGTH: 14 days; COURSE: continue for 1 to 2 cycles past the first normal hCG level.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
methotrexate PF 32 mg in sodium chloride 0.9 % 10 mL injection
32 mg (rounded from 31.76 mg = 0.4 mg/kg × 79.4 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Push over 2 to 5 minutes.
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Zztestonc,Edward E [2435061]
6/6/2017 6:24:44 PM Page 4 of 29
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.
Day 5, Cycle 1 – Planned for 6/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gestational Trophoblastic Neoplasia (Adjuvant/ Advanced); THERAPY: methotrexate 0.4 mg/kg IV Day 1,2,3,4, and 5;
CYCLE LENGTH: 14 days; COURSE: continue for 1 to 2 cycles past the first normal hCG level.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
methotrexate PF 32 mg in sodium chloride 0.9 % 10 mL injection
32 mg (rounded from 31.76 mg = 0.4 mg/kg × 79.4 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Push over 2 to 5 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8- Lab Only, Cycle 1 – Planned for 6/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gestational Trophoblastic Neoplasia (Adjuvant/ Advanced); THERAPY: methotrexate 0.4 mg/kg IV Day 1,2,3,4, and 5;
CYCLE LENGTH: 14 days; COURSE: continue for 1 to 2 cycles past the first normal hCG level.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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Zztestonc,Edward E [2435061]
6/6/2017 6:24:44 PM Page 5 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

CBC WITH DIFFERENTIAL
Expected-S+3 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 6/20/2017 through 7/3/2017 (14 days), Planned
Day 1, Cycle 2 – Planned for 6/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gestational Trophoblastic Neoplasia (Adjuvant/ Advanced); THERAPY: methotrexate 0.4 mg/kg IV Day 1,2,3,4, and 5;
CYCLE LENGTH: 14 days; COURSE: continue for 1 to 2 cycles past the first normal hCG level.
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 WITH DIFFERENTIAL
Expected-S+10 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+10 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+10 Approximate, Expires-S+365, Routine
HCG, QUANTITATIVE
Expected-S+10 Approximate, Expires-S+365, Routine
PROTEIN, TOTAL
Expected-S+10 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+10 Approximate, Expires-S+365, Routine
BILIRUBIN, DIRECT
Expected-S+10 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+10 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+10 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+10 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+10 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: ANC (DIFF if to be done locally), Platelets, Hemoglobin.
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Zztestonc,Edward E [2435061]
6/6/2017 6:24:44 PM Page 6 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,500/µL or Platelets less than 100K/µL, or Hemoglobin
less than 8 g/dL.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
methotrexate PF 32 mg in sodium chloride 0.9 % 10 mL injection
32 mg (rounded from 31.76 mg = 0.4 mg/kg × 79.4 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Push over 2 to 5 minutes.
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: methotrexate for 30 minutes.
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: methotrexate for 30 minutes.
DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: methotrexate for 30 minutes.
DAY 5 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: methotrexate for 30 minutes.
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 15 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Creatinine, Beta HCG, Total Protein, Albumin, Direct Bilirubin, Total Bilirubin, AST, ALT, Alkaline Phosphatase;
CHEMOTHERAPY ROOM APPOINTMENT: methotrexate for 30 minutes.
Day 2, Cycle 2 – Planned for 6/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gestational Trophoblastic Neoplasia (Adjuvant/ Advanced); THERAPY: methotrexate 0.4 mg/kg IV Day 1,2,3,4, and 5;
CYCLE LENGTH: 14 days; COURSE: continue for 1 to 2 cycles past the first normal hCG level.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
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Zztestonc,Edward E [2435061]
6/6/2017 6:24:44 PM Page 7 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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.
Treatment Medications
methotrexate PF 32 mg in sodium chloride 0.9 % 10 mL injection
32 mg (rounded from 31.76 mg = 0.4 mg/kg × 79.4 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Push over 2 to 5 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 2 – Planned for 6/22/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gestational Trophoblastic Neoplasia (Adjuvant/ Advanced); THERAPY: methotrexate 0.4 mg/kg IV Day 1,2,3,4, and 5;
CYCLE LENGTH: 14 days; COURSE: continue for 1 to 2 cycles past the first normal hCG level.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
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Zztestonc,Edward E [2435061]
6/6/2017 6:24:44 PM Page 8 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

methotrexate PF 32 mg in sodium chloride 0.9 % 10 mL injection
32 mg (rounded from 31.76 mg = 0.4 mg/kg × 79.4 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Push over 2 to 5 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 4, Cycle 2 – Planned for 6/23/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gestational Trophoblastic Neoplasia (Adjuvant/ Advanced); THERAPY: methotrexate 0.4 mg/kg IV Day 1,2,3,4, and 5;
CYCLE LENGTH: 14 days; COURSE: continue for 1 to 2 cycles past the first normal hCG level.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
methotrexate PF 32 mg in sodium chloride 0.9 % 10 mL injection
32 mg (rounded from 31.76 mg = 0.4 mg/kg × 79.4 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Push over 2 to 5 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 2 – Planned for 6/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gestational Trophoblastic Neoplasia (Adjuvant/ Advanced); THERAPY: methotrexate 0.4 mg/kg IV Day 1,2,3,4, and 5;
CYCLE LENGTH: 14 days; COURSE: continue for 1 to 2 cycles past the first normal hCG level.
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Edward E [2435061]
6/6/2017 6:24:44 PM Page 9 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
methotrexate PF 32 mg in sodium chloride 0.9 % 10 mL injection
32 mg (rounded from 31.76 mg = 0.4 mg/kg × 79.4 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Push over 2 to 5 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8- Lab Only, Cycle 2 – Planned for 6/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gestational Trophoblastic Neoplasia (Adjuvant/ Advanced); THERAPY: methotrexate 0.4 mg/kg IV Day 1,2,3,4, and 5;
CYCLE LENGTH: 14 days; COURSE: continue for 1 to 2 cycles past the first normal hCG level.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+3 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 – 7/4/2017 through 7/17/2017 (14 days), Planned
Day 1, Cycle 3 – Planned for 7/4/2017
Treatment Plan Information
Treatment Plan Summary
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Zztestonc,Edward E [2435061]
6/6/2017 6:24:44 PM Page 10 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

DISEASE: Gestational Trophoblastic Neoplasia (Adjuvant/ Advanced); THERAPY: methotrexate 0.4 mg/kg IV Day 1,2,3,4, and 5;
CYCLE LENGTH: 14 days; COURSE: continue for 1 to 2 cycles past the first normal hCG level.
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 WITH DIFFERENTIAL
Expected-S+10 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+10 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+10 Approximate, Expires-S+365, Routine
HCG, QUANTITATIVE
Expected-S+10 Approximate, Expires-S+365, Routine
PROTEIN, TOTAL
Expected-S+10 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+10 Approximate, Expires-S+365, Routine
BILIRUBIN, DIRECT
Expected-S+10 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+10 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+10 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+10 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+10 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: ANC (DIFF if to be done locally), Platelets, Hemoglobin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,500/µL or Platelets less than 100K/µL, or Hemoglobin less than 8 g/dL.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
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Zztestonc,Edward E [2435061]
6/6/2017 6:24:44 PM Page 11 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
methotrexate PF 32 mg in sodium chloride 0.9 % 10 mL injection
32 mg (rounded from 31.76 mg = 0.4 mg/kg × 79.4 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Push over 2 to 5 minutes.
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: methotrexate for 30 minutes.
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: methotrexate for 30 minutes.
DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: methotrexate for 30 minutes.
DAY 5 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: methotrexate for 30 minutes.
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 15 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Creatinine, Beta HCG, Total Protein, Albumin, Direct Bilirubin, Total Bilirubin, AST, ALT, Alkaline Phosphatase;
CHEMOTHERAPY ROOM APPOINTMENT: methotrexate for 30 minutes.
Day 2, Cycle 3 – Planned for 7/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gestational Trophoblastic Neoplasia (Adjuvant/ Advanced); THERAPY: methotrexate 0.4 mg/kg IV Day 1,2,3,4, and 5;
CYCLE LENGTH: 14 days; COURSE: continue for 1 to 2 cycles past the first normal hCG level.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
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Zztestonc,Edward E [2435061]
6/6/2017 6:24:44 PM Page 12 of 29
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.
Treatment Medications
methotrexate PF 32 mg in sodium chloride 0.9 % 10 mL injection
32 mg (rounded from 31.76 mg = 0.4 mg/kg × 79.4 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Push over 2 to 5 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 3 – Planned for 7/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gestational Trophoblastic Neoplasia (Adjuvant/ Advanced); THERAPY: methotrexate 0.4 mg/kg IV Day 1,2,3,4, and 5;
CYCLE LENGTH: 14 days; COURSE: continue for 1 to 2 cycles past the first normal hCG level.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
methotrexate PF 32 mg in sodium chloride 0.9 % 10 mL injection
32 mg (rounded from 31.76 mg = 0.4 mg/kg × 79.4 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Push over 2 to 5 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 4, Cycle 3 – Planned for 7/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gestational Trophoblastic Neoplasia (Adjuvant/ Advanced); THERAPY: methotrexate 0.4 mg/kg IV Day 1,2,3,4, and 5;
CYCLE LENGTH: 14 days; COURSE: continue for 1 to 2 cycles past the first normal hCG level.
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Zztestonc,Edward E [2435061]
6/6/2017 6:24:44 PM Page 13 of 29
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.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
methotrexate PF 32 mg in sodium chloride 0.9 % 10 mL injection
32 mg (rounded from 31.76 mg = 0.4 mg/kg × 79.4 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Push over 2 to 5 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 3 – Planned for 7/8/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gestational Trophoblastic Neoplasia (Adjuvant/ Advanced); THERAPY: methotrexate 0.4 mg/kg IV Day 1,2,3,4, and 5;
CYCLE LENGTH: 14 days; COURSE: continue for 1 to 2 cycles past the first normal hCG level.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
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Zztestonc,Edward E [2435061]
6/6/2017 6:24:44 PM Page 14 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
methotrexate PF 32 mg in sodium chloride 0.9 % 10 mL injection
32 mg (rounded from 31.76 mg = 0.4 mg/kg × 79.4 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Push over 2 to 5 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8- Lab Only, Cycle 3 – Planned for 7/11/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gestational Trophoblastic Neoplasia (Adjuvant/ Advanced); THERAPY: methotrexate 0.4 mg/kg IV Day 1,2,3,4, and 5;
CYCLE LENGTH: 14 days; COURSE: continue for 1 to 2 cycles past the first normal hCG level.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+3 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 – 7/18/2017 through 7/31/2017 (14 days), Planned
Day 1, Cycle 4 – Planned for 7/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gestational Trophoblastic Neoplasia (Adjuvant/ Advanced); THERAPY: methotrexate 0.4 mg/kg IV Day 1,2,3,4, and 5;
CYCLE LENGTH: 14 days; COURSE: continue for 1 to 2 cycles past the first normal hCG level.
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 WITH DIFFERENTIAL
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Zztestonc,Edward E [2435061]
6/6/2017 6:24:44 PM Page 15 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Expected-S+10 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+10 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+10 Approximate, Expires-S+365, Routine
HCG, QUANTITATIVE
Expected-S+10 Approximate, Expires-S+365, Routine
PROTEIN, TOTAL
Expected-S+10 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+10 Approximate, Expires-S+365, Routine
BILIRUBIN, DIRECT
Expected-S+10 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+10 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+10 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+10 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+10 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: ANC (DIFF if to be done locally), Platelets, Hemoglobin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,500/µL or Platelets less than 100K/µL, or Hemoglobin less than 8 g/dL.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
methotrexate PF 32 mg in sodium chloride 0.9 % 10 mL injection
32 mg (rounded from 31.76 mg = 0.4 mg/kg × 79.4 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Push over 2 to 5 minutes.
Follow-Up
DAY 2 FOLLOW-UP
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Zztestonc,Edward E [2435061]
6/6/2017 6:24:44 PM Page 16 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

CHEMOTHERAPY ROOM APPOINTMENT: methotrexate for 30 minutes.
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: methotrexate for 30 minutes.
DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: methotrexate for 30 minutes.
DAY 5 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: methotrexate for 30 minutes.
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 15 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Creatinine, Beta HCG, Total Protein, Albumin, Direct Bilirubin, Total Bilirubin, AST, ALT, Alkaline Phosphatase;
CHEMOTHERAPY ROOM APPOINTMENT: methotrexate for 30 minutes.
Day 2, Cycle 4 – Planned for 7/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gestational Trophoblastic Neoplasia (Adjuvant/ Advanced); THERAPY: methotrexate 0.4 mg/kg IV Day 1,2,3,4, and 5;
CYCLE LENGTH: 14 days; COURSE: continue for 1 to 2 cycles past the first normal hCG level.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
methotrexate PF 32 mg in sodium chloride 0.9 % 10 mL injection
32 mg (rounded from 31.76 mg = 0.4 mg/kg × 79.4 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Push over 2 to 5 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 4 – Planned for 7/20/2017
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Zztestonc,Edward E [2435061]
6/6/2017 6:24:44 PM Page 17 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Gestational Trophoblastic Neoplasia (Adjuvant/ Advanced); THERAPY: methotrexate 0.4 mg/kg IV Day 1,2,3,4, and 5;
CYCLE LENGTH: 14 days; COURSE: continue for 1 to 2 cycles past the first normal hCG level.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
methotrexate PF 32 mg in sodium chloride 0.9 % 10 mL injection
32 mg (rounded from 31.76 mg = 0.4 mg/kg × 79.4 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Push over 2 to 5 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 4, Cycle 4 – Planned for 7/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gestational Trophoblastic Neoplasia (Adjuvant/ Advanced); THERAPY: methotrexate 0.4 mg/kg IV Day 1,2,3,4, and 5;
CYCLE LENGTH: 14 days; COURSE: continue for 1 to 2 cycles past the first normal hCG level.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
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
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Zztestonc,Edward E [2435061]
6/6/2017 6:24:44 PM Page 18 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
methotrexate PF 32 mg in sodium chloride 0.9 % 10 mL injection
32 mg (rounded from 31.76 mg = 0.4 mg/kg × 79.4 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Push over 2 to 5 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 4 – Planned for 7/22/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gestational Trophoblastic Neoplasia (Adjuvant/ Advanced); THERAPY: methotrexate 0.4 mg/kg IV Day 1,2,3,4, and 5;
CYCLE LENGTH: 14 days; COURSE: continue for 1 to 2 cycles past the first normal hCG level.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
methotrexate PF 32 mg in sodium chloride 0.9 % 10 mL injection
32 mg (rounded from 31.76 mg = 0.4 mg/kg × 79.4 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Push over 2 to 5 minutes.
Follow-Up
VERIFY APPOINTMENTS
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Zztestonc,Edward E [2435061]
6/6/2017 6:24:44 PM Page 19 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8- Lab Only, Cycle 4 – Planned for 7/25/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gestational Trophoblastic Neoplasia (Adjuvant/ Advanced); THERAPY: methotrexate 0.4 mg/kg IV Day 1,2,3,4, and 5;
CYCLE LENGTH: 14 days; COURSE: continue for 1 to 2 cycles past the first normal hCG level.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+3 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 – 8/1/2017 through 8/14/2017 (14 days), Planned
Day 1, Cycle 5 – Planned for 8/1/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gestational Trophoblastic Neoplasia (Adjuvant/ Advanced); THERAPY: methotrexate 0.4 mg/kg IV Day 1,2,3,4, and 5;
CYCLE LENGTH: 14 days; COURSE: continue for 1 to 2 cycles past the first normal hCG level.
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 WITH DIFFERENTIAL
Expected-S+10 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+10 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+10 Approximate, Expires-S+365, Routine
HCG, QUANTITATIVE
Expected-S+10 Approximate, Expires-S+365, Routine
PROTEIN, TOTAL
Expected-S+10 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+10 Approximate, Expires-S+365, Routine
BILIRUBIN, DIRECT
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Zztestonc,Edward E [2435061]
6/6/2017 6:24:44 PM Page 20 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Expected-S+10 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+10 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+10 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+10 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+10 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: ANC (DIFF if to be done locally), Platelets, Hemoglobin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,500/µL or Platelets less than 100K/µL, or Hemoglobin less than 8 g/dL.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
methotrexate PF 32 mg in sodium chloride 0.9 % 10 mL injection
32 mg (rounded from 31.76 mg = 0.4 mg/kg × 79.4 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Push over 2 to 5 minutes.
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: methotrexate for 30 minutes.
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: methotrexate for 30 minutes.
DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: methotrexate for 30 minutes.
DAY 5 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: methotrexate for 30 minutes.
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 15 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Creatinine, Beta HCG, Total Protein, Albumin, Direct Bilirubin, Total Bilirubin, AST, ALT, Alkaline Phosphatase;
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Zztestonc,Edward E [2435061]
6/6/2017 6:24:44 PM Page 21 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

CHEMOTHERAPY ROOM APPOINTMENT: methotrexate for 30 minutes.
Day 2, Cycle 5 – Planned for 8/2/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gestational Trophoblastic Neoplasia (Adjuvant/ Advanced); THERAPY: methotrexate 0.4 mg/kg IV Day 1,2,3,4, and 5;
CYCLE LENGTH: 14 days; COURSE: continue for 1 to 2 cycles past the first normal hCG level.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
methotrexate PF 32 mg in sodium chloride 0.9 % 10 mL injection
32 mg (rounded from 31.76 mg = 0.4 mg/kg × 79.4 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Push over 2 to 5 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 5 – Planned for 8/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gestational Trophoblastic Neoplasia (Adjuvant/ Advanced); THERAPY: methotrexate 0.4 mg/kg IV Day 1,2,3,4, and 5;
CYCLE LENGTH: 14 days; COURSE: continue for 1 to 2 cycles past the first normal hCG level.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
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Zztestonc,Edward E [2435061]
6/6/2017 6:24:44 PM Page 22 of 29
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
methotrexate PF 32 mg in sodium chloride 0.9 % 10 mL injection
32 mg (rounded from 31.76 mg = 0.4 mg/kg × 79.4 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Push over 2 to 5 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 4, Cycle 5 – Planned for 8/4/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gestational Trophoblastic Neoplasia (Adjuvant/ Advanced); THERAPY: methotrexate 0.4 mg/kg IV Day 1,2,3,4, and 5;
CYCLE LENGTH: 14 days; COURSE: continue for 1 to 2 cycles past the first normal hCG level.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
methotrexate PF 32 mg in sodium chloride 0.9 % 10 mL injection
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Zztestonc,Edward E [2435061]
6/6/2017 6:24:44 PM Page 23 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

32 mg (rounded from 31.76 mg = 0.4 mg/kg × 79.4 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Push over 2 to 5 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 5 – Planned for 8/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gestational Trophoblastic Neoplasia (Adjuvant/ Advanced); THERAPY: methotrexate 0.4 mg/kg IV Day 1,2,3,4, and 5;
CYCLE LENGTH: 14 days; COURSE: continue for 1 to 2 cycles past the first normal hCG level.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
methotrexate PF 32 mg in sodium chloride 0.9 % 10 mL injection
32 mg (rounded from 31.76 mg = 0.4 mg/kg × 79.4 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Push over 2 to 5 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8- Lab Only, Cycle 5 – Planned for 8/8/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gestational Trophoblastic Neoplasia (Adjuvant/ Advanced); THERAPY: methotrexate 0.4 mg/kg IV Day 1,2,3,4, and 5;
CYCLE LENGTH: 14 days; COURSE: continue for 1 to 2 cycles past the first normal hCG level.
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Edward E [2435061]
6/6/2017 6:24:44 PM Page 24 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+3 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 – 8/15/2017 through 8/28/2017 (14 days), Planned
Day 1, Cycle 6 – Planned for 8/15/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gestational Trophoblastic Neoplasia (Adjuvant/ Advanced); THERAPY: methotrexate 0.4 mg/kg IV Day 1,2,3,4, and 5;
CYCLE LENGTH: 14 days; COURSE: continue for 1 to 2 cycles past the first normal hCG level.
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 WITH DIFFERENTIAL
Expected-S+10 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+10 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+10 Approximate, Expires-S+365, Routine
HCG, QUANTITATIVE
Expected-S+10 Approximate, Expires-S+365, Routine
PROTEIN, TOTAL
Expected-S+10 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+10 Approximate, Expires-S+365, Routine
BILIRUBIN, DIRECT
Expected-S+10 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+10 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+10 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+10 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+10 Approximate, Expires-S+365, Routine
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Zztestonc,Edward E [2435061]
6/6/2017 6:24:44 PM Page 25 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: ANC (DIFF if to be done locally), Platelets, Hemoglobin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,500/µL or Platelets less than 100K/µL, or Hemoglobin less than 8 g/dL.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
methotrexate PF 32 mg in sodium chloride 0.9 % 10 mL injection
32 mg (rounded from 31.76 mg = 0.4 mg/kg × 79.4 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Push over 2 to 5 minutes.
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: methotrexate for 30 minutes.
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: methotrexate for 30 minutes.
DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: methotrexate for 30 minutes.
DAY 5 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: methotrexate for 30 minutes.
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 15 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Creatinine, Beta HCG, Total Protein, Albumin, Direct Bilirubin, Total Bilirubin, AST, ALT, Alkaline Phosphatase;
CHEMOTHERAPY ROOM APPOINTMENT: methotrexate for 30 minutes.
Day 2, Cycle 6 – Planned for 8/16/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gestational Trophoblastic Neoplasia (Adjuvant/ Advanced); THERAPY: methotrexate 0.4 mg/kg IV Day 1,2,3,4, and 5;
CYCLE LENGTH: 14 days; COURSE: continue for 1 to 2 cycles past the first normal hCG level.
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Edward E [2435061]
6/6/2017 6:24:44 PM Page 26 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
methotrexate PF 32 mg in sodium chloride 0.9 % 10 mL injection
32 mg (rounded from 31.76 mg = 0.4 mg/kg × 79.4 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Push over 2 to 5 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 6 – Planned for 8/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gestational Trophoblastic Neoplasia (Adjuvant/ Advanced); THERAPY: methotrexate 0.4 mg/kg IV Day 1,2,3,4, and 5;
CYCLE LENGTH: 14 days; COURSE: continue for 1 to 2 cycles past the first normal hCG level.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
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Zztestonc,Edward E [2435061]
6/6/2017 6:24:44 PM Page 27 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
methotrexate PF 32 mg in sodium chloride 0.9 % 10 mL injection
32 mg (rounded from 31.76 mg = 0.4 mg/kg × 79.4 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Push over 2 to 5 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 4, Cycle 6 – Planned for 8/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gestational Trophoblastic Neoplasia (Adjuvant/ Advanced); THERAPY: methotrexate 0.4 mg/kg IV Day 1,2,3,4, and 5;
CYCLE LENGTH: 14 days; COURSE: continue for 1 to 2 cycles past the first normal hCG level.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
methotrexate PF 32 mg in sodium chloride 0.9 % 10 mL injection
32 mg (rounded from 31.76 mg = 0.4 mg/kg × 79.4 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Push over 2 to 5 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 6 – Planned for 8/19/2017
Treatment Plan Information
Treatment Plan Summary
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Zztestonc,Edward E [2435061]
6/6/2017 6:24:44 PM Page 28 of 29
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

DISEASE: Gestational Trophoblastic Neoplasia (Adjuvant/ Advanced); THERAPY: methotrexate 0.4 mg/kg IV Day 1,2,3,4, and 5;
CYCLE LENGTH: 14 days; COURSE: continue for 1 to 2 cycles past the first normal hCG level.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
methotrexate PF 32 mg in sodium chloride 0.9 % 10 mL injection
32 mg (rounded from 31.76 mg = 0.4 mg/kg × 79.4 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Push over 2 to 5 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8- Lab Only, Cycle 6 – Planned for 8/22/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gestational Trophoblastic Neoplasia (Adjuvant/ Advanced); THERAPY: methotrexate 0.4 mg/kg IV Day 1,2,3,4, and 5;
CYCLE LENGTH: 14 days; COURSE: continue for 1 to 2 cycles past the first normal hCG level.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+3 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 6:24:44 PM Page 29 of 29
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