/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-96772-en.cckm

201706157

page

100

UWHC,UWMF,

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

CSC GYN Paclitaxel(21D:1) VER 1-11-17(HL 1790)

CSC GYN Paclitaxel(21D:1) VER 1-11-17(HL 1790) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GYN


CSC GYN PACLITAXEL(21D:1) 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, Fallopian Tube, Peritoneal, Uterine Sarcoma Cancer (Adjuvant or Advanced); THERAPY: PACLItaxel 175
mg/m2 IV Day 1; CYCLE LENGTH: 21 days; COURSE: Up to 6 cycles (Adjuvant) or until disease progression (Advanced)
Treatment Plan Summary (2)
DISEASE: Uterine Sarcoma with prior irradiation (Advanced); THERAPY: PACLItaxel 135 mg/m2 IV Day 1; CYCLE LENGTH: 21
days; COURSE: Until disease progression (Advanced)
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Normal, Routine
ELECTROLYTES
Expected-S Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Normal, Routine
MAGNESIUM
Expected-S Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S Approximate, Expires-S+365, Normal, Routine
CA 125
Expected-S Approximate, Expires-S+365, Normal, Routine
Order for ovarian cancer, fallopian tube cancer or peritoneal cancer only.
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
Take 5 tabs 12&6 hrs prior to 1st PACLItaxel dose, 3 tabs 12&6 hrs prior to 2nd dose, 2 tabs 12&6 hrs prior to 3rd dose, Disp-20
tab, R-0, 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)
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Zztestonc,Edward E [2435061]
6/6/2017 5:41:52 PM Page 1 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

OVARIAN CANCER/FALLOPIAN TUBE CANCER/PERITONEAL CANCER: ten Bokkel Huinink W, et al. J Clin Oncol. 1997;15
(6):2183-93.
Reference Information (2)
UTERINE SARCOMA: Curtin J, et al. Gynecol Oncol. 2001;83(2):268-70.
Treatment Plan Summary
DISEASE: Ovarian, Fallopian Tube, Peritoneal, Uterine Sarcoma Cancer (Adjuvant or Advanced); THERAPY: PACLItaxel 175
mg/m2 IV Day 1; CYCLE LENGTH: 21 days; COURSE: Up to 6 cycles (Adjuvant) or until disease progression (Advanced)
Treatment Plan Summary (2)
DISEASE: Uterine Sarcoma with prior irradiation (Advanced); THERAPY: PACLItaxel 135 mg/m2 IV Day 1; CYCLE LENGTH: 21
days; COURSE: Until disease progression (Advanced)
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, Platelets
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1500/µL or Platelets less than or equal to 100K/µL.
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
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Zztestonc,Edward E [2435061]
6/6/2017 5:41:52 PM Page 2 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Pre-Medications
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.
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.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 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) in dextrose 5 % 100 mL non-PVC bag
Intravenous, ONCE, 1 dose Starting when released
MAXIMUM BSA = 2 m2 (per physician discretion). Hypersensitivity risk. See emergency medications. Infuse over 180 minutes. Use
non-PVC tubing and 0.2 or 0.22 micron in-line filter during administration. Dose = 135 mg/m2 if patient has received prior irradiation
(dose reduction for uterine sarcoma only).
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC without DIFF, ANC (DIFF if drawn locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Electrolytes,
Creatinine, Magnesium, Total Bilirubin, AST, Alkaline Phosphatase, CA 125 (if applicable); CHEMOTHERAPY ROOM
APPOINTMENT: PACLItaxel for 240 minutes
Day 10 (Lab Only), Cycle 1 – Planned for 6/15/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Fallopian Tube, Peritoneal, Uterine Sarcoma Cancer (Adjuvant or Advanced); THERAPY: PACLItaxel 175
mg/m2 IV Day 1; CYCLE LENGTH: 21 days; COURSE: Up to 6 cycles (Adjuvant) or until disease progression (Advanced)
Treatment Plan Summary (2)
DISEASE: Uterine Sarcoma with prior irradiation (Advanced); THERAPY: PACLItaxel 135 mg/m2 IV Day 1; CYCLE LENGTH: 21
days; COURSE: Until disease progression (Advanced)
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 5:41:52 PM Page 3 of 17
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+9 Approximate, Expires-S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Normal, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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, Fallopian Tube, Peritoneal, Uterine Sarcoma Cancer (Adjuvant or Advanced); THERAPY: PACLItaxel 175
mg/m2 IV Day 1; CYCLE LENGTH: 21 days; COURSE: Up to 6 cycles (Adjuvant) or until disease progression (Advanced)
Treatment Plan Summary (2)
DISEASE: Uterine Sarcoma with prior irradiation (Advanced); THERAPY: PACLItaxel 135 mg/m2 IV Day 1; CYCLE LENGTH: 21
days; COURSE: Until disease progression (Advanced)
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+21 Approximate, Expires-S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
ELECTROLYTES
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
MAGNESIUM
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
CA 125
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
Order for ovarian cancer, fallopian tube cancer or peritoneal cancer only.
Treatment Conditions
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Zztestonc,Edward E [2435061]
6/6/2017 5:41:52 PM Page 4 of 17
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: ANC, Platelets
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1500/µL or Platelets less than or equal to 100K/µL.
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
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.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, PRN - NOTIFY PHARMACY WHEN NEEDED Starting when released Until Discontinued, If PO not taken at
home.
For use in patients who did not take dexamethasone at home. Notify pharmacy that medication is needed
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
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Zztestonc,Edward E [2435061]
6/6/2017 5:41:52 PM Page 5 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

dexamethasone (DECADRON) 10 MG/ML injection 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) in dextrose 5 % 100 mL non-PVC bag
Intravenous, ONCE, 1 dose Starting when released
MAXIMUM BSA = 2 m2 (per physician discretion). Hypersensitivity risk. See emergency medications. Infuse over 180 minutes. Use
non-PVC tubing and 0.2 or 0.22 micron in-line filter during administration. Dose = 135 mg/m2 if patient has received prior irradiation
(dose reduction for uterine sarcoma only).
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC without DIFF, ANC (DIFF if drawn locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Electrolytes,
Creatinine, Magnesium, Total Bilirubin, AST, Alkaline Phosphatase, CA 125 (if applicable); CHEMOTHERAPY ROOM
APPOINTMENT: PACLItaxel for 240 minutes
Day 10 (Lab Only), Cycle 2 – Planned for 7/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Fallopian Tube, Peritoneal, Uterine Sarcoma Cancer (Adjuvant or Advanced); THERAPY: PACLItaxel 175
mg/m2 IV Day 1; CYCLE LENGTH: 21 days; COURSE: Up to 6 cycles (Adjuvant) or until disease progression (Advanced)
Treatment Plan Summary (2)
DISEASE: Uterine Sarcoma with prior irradiation (Advanced); THERAPY: PACLItaxel 135 mg/m2 IV Day 1; CYCLE LENGTH: 21
days; COURSE: Until disease progression (Advanced)
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+9 Approximate, Expires-S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Normal, 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, Fallopian Tube, Peritoneal, Uterine Sarcoma Cancer (Adjuvant or Advanced); THERAPY: PACLItaxel 175
mg/m2 IV Day 1; CYCLE LENGTH: 21 days; COURSE: Up to 6 cycles (Adjuvant) or until disease progression (Advanced)
Treatment Plan Summary (2)
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Zztestonc,Edward E [2435061]
6/6/2017 5:41:52 PM Page 6 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

DISEASE: Uterine Sarcoma with prior irradiation (Advanced); THERAPY: PACLItaxel 135 mg/m2 IV Day 1; CYCLE LENGTH: 21
days; COURSE: Until disease progression (Advanced)
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+21 Approximate, Expires-S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
ELECTROLYTES
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
MAGNESIUM
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
CA 125
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
Order for ovarian cancer, fallopian tube cancer or peritoneal cancer only.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: ANC, Platelets
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1500/µL or Platelets less than or equal to 100K/µL.
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
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Zztestonc,Edward E [2435061]
6/6/2017 5:41:52 PM Page 7 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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
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.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, PRN - NOTIFY PHARMACY WHEN NEEDED Starting when released Until Discontinued, If PO not taken at
home.
For use in patients who did not take dexamethasone at home. Notify pharmacy that medication is needed
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) in dextrose 5 % 100 mL non-PVC bag
Intravenous, ONCE, 1 dose Starting when released
MAXIMUM BSA = 2 m2 (per physician discretion). Hypersensitivity risk. See emergency medications. Infuse over 180 minutes. Use
non-PVC tubing and 0.2 or 0.22 micron in-line filter during administration. Dose = 135 mg/m2 if patient has received prior irradiation
(dose reduction for uterine sarcoma only).
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC without DIFF, ANC (DIFF if drawn locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Electrolytes,
Creatinine, Magnesium, Total Bilirubin, AST, Alkaline Phosphatase, CA 125 (if applicable); CHEMOTHERAPY ROOM
APPOINTMENT: PACLItaxel for 240 minutes
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Zztestonc,Edward E [2435061]
6/6/2017 5:41:52 PM Page 8 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Day 10 (Lab Only), Cycle 3 – Planned for 7/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Fallopian Tube, Peritoneal, Uterine Sarcoma Cancer (Adjuvant or Advanced); THERAPY: PACLItaxel 175
mg/m2 IV Day 1; CYCLE LENGTH: 21 days; COURSE: Up to 6 cycles (Adjuvant) or until disease progression (Advanced)
Treatment Plan Summary (2)
DISEASE: Uterine Sarcoma with prior irradiation (Advanced); THERAPY: PACLItaxel 135 mg/m2 IV Day 1; CYCLE LENGTH: 21
days; COURSE: Until disease progression (Advanced)
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+9 Approximate, Expires-S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Normal, 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
DISEASE: Ovarian, Fallopian Tube, Peritoneal, Uterine Sarcoma Cancer (Adjuvant or Advanced); THERAPY: PACLItaxel 175
mg/m2 IV Day 1; CYCLE LENGTH: 21 days; COURSE: Up to 6 cycles (Adjuvant) or until disease progression (Advanced)
Treatment Plan Summary (2)
DISEASE: Uterine Sarcoma with prior irradiation (Advanced); THERAPY: PACLItaxel 135 mg/m2 IV Day 1; CYCLE LENGTH: 21
days; COURSE: Until disease progression (Advanced)
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+21 Approximate, Expires-S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
ELECTROLYTES
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
CREATININE
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Zztestonc,Edward E [2435061]
6/6/2017 5:41:52 PM Page 9 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Expected-S+21 Approximate, Expires-S+365, Normal, Routine
MAGNESIUM
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
CA 125
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
Order for ovarian cancer, fallopian tube cancer or peritoneal cancer only.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: ANC, Platelets
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1500/µL or Platelets less than or equal to 100K/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. 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
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
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
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Zztestonc,Edward E [2435061]
6/6/2017 5:41:52 PM Page 10 of 17
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 5 Minutes
Give 30 minutes prior to PACLItaxel.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 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) in dextrose 5 % 100 mL non-PVC bag
Intravenous, ONCE, 1 dose Starting when released
MAXIMUM BSA = 2 m2 (per physician discretion). Hypersensitivity risk. See emergency medications. Infuse over 180 minutes. Use
non-PVC tubing and 0.2 or 0.22 micron in-line filter during administration. Dose = 135 mg/m2 if patient has received prior irradiation
(dose reduction for uterine sarcoma only).
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC without DIFF, ANC (DIFF if drawn locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Electrolytes,
Creatinine, Magnesium, Total Bilirubin, AST, Alkaline Phosphatase, CA 125 (if applicable); CHEMOTHERAPY ROOM
APPOINTMENT: PACLItaxel for 240 minutes
Day 10 (Lab Only), Cycle 4 – Planned for 8/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Fallopian Tube, Peritoneal, Uterine Sarcoma Cancer (Adjuvant or Advanced); THERAPY: PACLItaxel 175
mg/m2 IV Day 1; CYCLE LENGTH: 21 days; COURSE: Up to 6 cycles (Adjuvant) or until disease progression (Advanced)
Treatment Plan Summary (2)
DISEASE: Uterine Sarcoma with prior irradiation (Advanced); THERAPY: PACLItaxel 135 mg/m2 IV Day 1; CYCLE LENGTH: 21
days; COURSE: Until disease progression (Advanced)
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+9 Approximate, Expires-S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Normal, Routine
Follow-Up
VERIFY APPOINTMENTS
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Zztestonc,Edward E [2435061]
6/6/2017 5:41:52 PM Page 11 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 – 8/29/2017 through 9/18/2017 (21 days), Planned
Day 1, Cycle 5 – Planned for 8/29/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Fallopian Tube, Peritoneal, Uterine Sarcoma Cancer (Adjuvant or Advanced); THERAPY: PACLItaxel 175
mg/m2 IV Day 1; CYCLE LENGTH: 21 days; COURSE: Up to 6 cycles (Adjuvant) or until disease progression (Advanced)
Treatment Plan Summary (2)
DISEASE: Uterine Sarcoma with prior irradiation (Advanced); THERAPY: PACLItaxel 135 mg/m2 IV Day 1; CYCLE LENGTH: 21
days; COURSE: Until disease progression (Advanced)
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+21 Approximate, Expires-S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
ELECTROLYTES
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
MAGNESIUM
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
CA 125
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
Order for ovarian cancer, fallopian tube cancer or peritoneal cancer only.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: ANC, Platelets
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1500/µL or Platelets less than or equal to 100K/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. See Emergency Medications.
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Zztestonc,Edward E [2435061]
6/6/2017 5:41:52 PM Page 12 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

** 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
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
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.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 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) in dextrose 5 % 100 mL non-PVC bag
Intravenous, ONCE, 1 dose Starting when released
MAXIMUM BSA = 2 m2 (per physician discretion). Hypersensitivity risk. See emergency medications. Infuse over 180 minutes. Use
non-PVC tubing and 0.2 or 0.22 micron in-line filter during administration. Dose = 135 mg/m2 if patient has received prior irradiation
(dose reduction for uterine sarcoma only).
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Zztestonc,Edward E [2435061]
6/6/2017 5:41:52 PM Page 13 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC without DIFF, ANC (DIFF if drawn locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Electrolytes,
Creatinine, Magnesium, Total Bilirubin, AST, Alkaline Phosphatase, CA 125 (if applicable); CHEMOTHERAPY ROOM
APPOINTMENT: PACLItaxel for 240 minutes
Day 10 (Lab Only), Cycle 5 – Planned for 9/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Fallopian Tube, Peritoneal, Uterine Sarcoma Cancer (Adjuvant or Advanced); THERAPY: PACLItaxel 175
mg/m2 IV Day 1; CYCLE LENGTH: 21 days; COURSE: Up to 6 cycles (Adjuvant) or until disease progression (Advanced)
Treatment Plan Summary (2)
DISEASE: Uterine Sarcoma with prior irradiation (Advanced); THERAPY: PACLItaxel 135 mg/m2 IV Day 1; CYCLE LENGTH: 21
days; COURSE: Until disease progression (Advanced)
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+9 Approximate, Expires-S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Normal, 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, Fallopian Tube, Peritoneal, Uterine Sarcoma Cancer (Adjuvant or Advanced); THERAPY: PACLItaxel 175
mg/m2 IV Day 1; CYCLE LENGTH: 21 days; COURSE: Up to 6 cycles (Adjuvant) or until disease progression (Advanced)
Treatment Plan Summary (2)
DISEASE: Uterine Sarcoma with prior irradiation (Advanced); THERAPY: PACLItaxel 135 mg/m2 IV Day 1; CYCLE LENGTH: 21
days; COURSE: Until disease progression (Advanced)
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
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Zztestonc,Edward E [2435061]
6/6/2017 5:41:52 PM Page 14 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

CBC WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
ELECTROLYTES
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
MAGNESIUM
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
CA 125
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
Order for ovarian cancer, fallopian tube cancer or peritoneal cancer only.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: ANC, Platelets
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1500/µL or Platelets less than or equal to 100K/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. 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
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Zztestonc,Edward E [2435061]
6/6/2017 5:41:52 PM Page 15 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Pre-Medications
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
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.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 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) in dextrose 5 % 100 mL non-PVC bag
Intravenous, ONCE, 1 dose Starting when released
MAXIMUM BSA = 2 m2 (per physician discretion). Hypersensitivity risk. See emergency medications. Infuse over 180 minutes. Use
non-PVC tubing and 0.2 or 0.22 micron in-line filter during administration. Dose = 135 mg/m2 if patient has received prior irradiation
(dose reduction for uterine sarcoma only).
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC without DIFF, ANC (DIFF if drawn locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Electrolytes,
Creatinine, Magnesium, Total Bilirubin, AST, Alkaline Phosphatase, CA 125 (if applicable); CHEMOTHERAPY ROOM
APPOINTMENT: PACLItaxel for 240 minutes
Day 10 (Lab Only), Cycle 6 – Planned for 9/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian, Fallopian Tube, Peritoneal, Uterine Sarcoma Cancer (Adjuvant or Advanced); THERAPY: PACLItaxel 175
mg/m2 IV Day 1; CYCLE LENGTH: 21 days; COURSE: Up to 6 cycles (Adjuvant) or until disease progression (Advanced)
Treatment Plan Summary (2)
DISEASE: Uterine Sarcoma with prior irradiation (Advanced); THERAPY: PACLItaxel 135 mg/m2 IV Day 1; CYCLE LENGTH: 21
days; COURSE: Until disease progression (Advanced)
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 5:41:52 PM Page 16 of 17
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+9 Approximate, Expires-S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Normal, 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 5:41:52 PM Page 17 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org