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CSC GYN Methotrexate(Weekly) VER 1-11-17 (HL 497)

CSC GYN Methotrexate(Weekly) VER 1-11-17 (HL 497) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GYN


CSC GYN METHOTREXATE (WEEKLY) 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
Therapy Plan Summary
Starting when released Until Specified
DISEASE: Gestational Trophoblastic Neoplasia (Adjuvant/Advanced); THERAPY: methotrexate 30 to 50mg/m2 IM or IV weekly;
CYCLE LENGTH: 7 days; COURSE: Continue 1 to 2 courses past first normal hCG level.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
HCG, QUANTITATIVE
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 for nausea/vomiting., 8 mg, Disp-30 tab, R-5, EVERY 8 HOURS PRN starting S,
Local Printer
Cycle 1 – 6/6/2017 through 6/12/2017 (7 days), Planned
Day 1, Cycle 1 – Planned for 6/6/2017
Treatment Plan Information
Reference Information (1)
GESTATIONAL TROPHOBLASTIC NEOPLASIA: Homeslely HD, et al. Am J Obstset Gynecol 1998;72:413-8
Therapy Plan Summary
Starting when released Until Specified
DISEASE: Gestational Trophoblastic Neoplasia (Adjuvant/Advanced); THERAPY: methotrexate 30 to 50mg/m2 IM or IV weekly;
CYCLE LENGTH: 7 days; COURSE: Continue 1 to 2 courses past 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.
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Zztestonc,Edward E [2435061]
6/6/2017 5:18:55 PM Page 1 of 4
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: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than upper limits of normal.
Treatment Medications
methotrexate PF (TREXALL) injection
Intramuscular, ONCE, 1 dose Starting when released
Follow-Up
DAY 8 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINC: for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine,
AST, Total Bilirubin, Beta HCG; CHEMOTHERAPY ROOM APPOINTMENT: methotrexate for 30 minutes.
Cycle 2 – 6/13/2017 through 6/19/2017 (7 days), Planned
Day 1, Cycle 2 – Planned for 6/13/2017
Treatment Plan Information
Therapy Plan Summary
Starting when released Until Specified
DISEASE: Gestational Trophoblastic Neoplasia (Adjuvant/Advanced); THERAPY: methotrexate 30 to 50mg/m2 IM or IV weekly;
CYCLE LENGTH: 7 days; COURSE: Continue 1 to 2 courses past 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 WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
HCG, QUANTITATIVE
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
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Zztestonc,Edward E [2435061]
6/6/2017 5:18:55 PM Page 2 of 4
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than upper limits of normal.
Treatment Medications
methotrexate PF (TREXALL) injection
Intramuscular, ONCE, 1 dose Starting when released
Follow-Up
DAY 8 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINC: for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine,
AST, Total Bilirubin, Beta HCG; CHEMOTHERAPY ROOM APPOINTMENT: methotrexate for 30 minutes.
Cycle 3 – 6/20/2017 through 6/26/2017 (7 days), Planned
Day 1, Cycle 3 – Planned for 6/20/2017
Treatment Plan Information
Therapy Plan Summary
Starting when released Until Specified
DISEASE: Gestational Trophoblastic Neoplasia (Adjuvant/Advanced); THERAPY: methotrexate 30 to 50mg/m2 IM or IV weekly;
CYCLE LENGTH: 7 days; COURSE: Continue 1 to 2 courses past 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 WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
HCG, QUANTITATIVE
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than upper limits of normal.
Treatment Medications
methotrexate PF (TREXALL) injection
Intramuscular, ONCE, 1 dose Starting when released
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Zztestonc,Edward E [2435061]
6/6/2017 5:18:55 PM Page 3 of 4
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Follow-Up
DAY 8 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINC: for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine,
AST, Total Bilirubin, Beta HCG; CHEMOTHERAPY ROOM APPOINTMENT: methotrexate for 30 minutes.
Actions
Actions
Zztestonc,Edward E [2435061]
6/6/2017 5:18:55 PM Page 4 of 4
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org