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/clinical/cckm-tools/content/beacon-protocols/head-and-neck/name-96793-en.cckm

201711317

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Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Beacon Protocols,Head and Neck

CSC HEAD/NECK Concurrent XRT Cisplatin(21D:1) VER 11-10-17 (HL 978)

CSC HEAD/NECK Concurrent XRT Cisplatin(21D:1) VER 11-10-17 (HL 978) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Head and Neck


CSC HEAD/NECK CONCURRENT XRT CISPLATIN(21D:1) VER: 11/10/17 –  Properties
Pre-Cycle –  11/6/2017 through 11/12/2017 (7 days), Planned
Day 1, Pre-Cycle –  Planned for 11/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Head and Neck Cancer (Adjuvant/Advanced); THERAPY: CISplatin 100 mg/m2 IV on Day 1 concurrent with
radiotherapy; CYCLE LENGTH: 21 days; COURSE:  3 cycles or until end of radiotherapy.
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
ELECTROLYTES
Expected: S Approximate, Expires: S+365, Routine
BUN
Expected: S Approximate, Expires: S+365, Routine
CREATININE
Expected: S Approximate, Expires: S+396, Routine
CALCIUM
Expected: S Approximate, Expires: S+365, Routine
ALBUMIN
Expected: S Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S Approximate, Expires: S+365, Routine
Take Home Medications
aprepitant (EMEND) 80 MG cap
Take 1 cap by mouth one time daily. Take for 2 days following chemotherapy., 80 mg, Disp-2 cap, R-5, 1 X DAILY
starting S
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Zztestonc,PedsBeiber [2668824]
11/13/2017 9:46:12 AM Page 1 of 9
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

dexamethasone (DECADRON) 4 MG tab
Take 2 tabs by mouth one time daily. Take for 3 days following chemotherapy., 8 mg, Disp-24 tab, R-5, 1 X DAILY
starting S
prochlorperazine (COMPAZINE) 10 MG tab
Take 1 tab by mouth every 6 hours as needed for nausea/vomiting., 10 mg, Disp-30 tab, R-5, EVERY 6 HOURS PRN
starting S
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 –  11/13/2017 through 12/3/2017 (21 days), Planned
Day 1, Cycle 1 –  Planned for 11/13/2017
Treatment Plan Information
Reference Information (1)
HEAD/NECK: Bernier J, et al. N Engl J Med 2004;350:1945-52.
Reference Information (2)
HEAD/NECK: Adelstein DJ, et al. J Clin Oncol 2003;21:92-8.
Treatment Plan Summary
DISEASE: Head and Neck Cancer (Adjuvant/Advanced); THERAPY: CISplatin 100 mg/m2 IV on Day 1 concurrent with
radiotherapy; CYCLE LENGTH: 21 days; COURSE:  3 cycles or until end of radiotherapy.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL
or Creatinine greater than ULN.
Nursing Procedure, Assessment and Monitoring
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
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Zztestonc,PedsBeiber [2668824]
11/13/2017 9:46:12 AM Page 2 of 9
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@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 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
sodium chloride 0.9 % infusion 500 mL
at 250-500 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
POST CISPLATIN HYDRATION. Delete if not needed.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
CISplatin (PLATINOL) 100 mg/m2 in sodium chloride 0.9 % 1,000 mL bag
100 mg/m2, Intravenous, ONCE, 1 dose Starting when released
For 60 to 90 minutes.
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, BUN, Creatinine, Calcium, Alkaline Phosphatase, AST, Albumin, Magnesium, Glucose, and Total Bilirubin;
CHEMOTHERAPY ROOM APPOINTMENT:  CISplatin for 240 minutes.
Lab Only - Day 10, Cycle 1 –  Planned for 11/22/2017
Treatment Plan Information
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Zztestonc,PedsBeiber [2668824]
11/13/2017 9:46:12 AM Page 3 of 9
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Head and Neck Cancer (Adjuvant/Advanced); THERAPY: CISplatin 100 mg/m2 IV on Day 1
concurrent with radiotherapy; CYCLE LENGTH: 21 days; COURSE:  3 cycles or until end of radiotherapy.
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, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+9 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 –  12/4/2017 through 12/24/2017 (21 days), Planned
Day 1, Cycle 2 –  Planned for 12/4/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Head and Neck Cancer (Adjuvant/Advanced); THERAPY: CISplatin 100 mg/m2 IV on Day 1 concurrent with
radiotherapy; CYCLE LENGTH: 21 days; COURSE:  3 cycles or until end of radiotherapy.
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, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+21 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+21 Approximate, Expires: S+365, Routine
BUN
Expected: S+21 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+21 Approximate, Expires: S+365, Routine
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Zztestonc,PedsBeiber [2668824]
11/13/2017 9:46:12 AM Page 4 of 9
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

CALCIUM
Expected: S+21 Approximate, Expires: S+365, Routine
ALBUMIN
Expected: S+21 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+21 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+21 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+21 Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S+21 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+21 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 ULN.
Nursing Procedure, Assessment and Monitoring
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
sodium chloride 0.9 % infusion 500 mL
at 250-500 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
POST CISPLATIN HYDRATION. Delete if not needed.
Pre-Medications
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Zztestonc,PedsBeiber [2668824]
11/13/2017 9:46:12 AM Page 5 of 9
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
CISplatin (PLATINOL) 100 mg/m2 in sodium chloride 0.9 % 1,000 mL bag
100 mg/m2, Intravenous, ONCE, 1 dose Starting when released
For 60 to 90 minutes.
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, BUN, Creatinine, Calcium, Alkaline Phosphatase, AST, Albumin, Magnesium, Glucose, and Total Bilirubin;
CHEMOTHERAPY ROOM APPOINTMENT:  CISplatin for 240 minutes.
Lab Only - Day 10, Cycle 2 –  Planned for 12/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Head and Neck Cancer (Adjuvant/Advanced); THERAPY: CISplatin 100 mg/m2 IV on Day 1 concurrent with
radiotherapy; CYCLE LENGTH: 21 days; COURSE:  3 cycles or until end of radiotherapy.
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, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+9 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 –  12/25/2017 through 1/14/2018 (21 days), Planned
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Zztestonc,PedsBeiber [2668824]
11/13/2017 9:46:12 AM Page 6 of 9
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

Day 1, Cycle 3 –  Planned for 12/25/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Head and Neck Cancer (Adjuvant/Advanced); THERAPY: CISplatin 100 mg/m2 IV on Day 1 concurrent with
radiotherapy; CYCLE LENGTH: 21 days; COURSE:  3 cycles or until end of radiotherapy.
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, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+21 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+21 Approximate, Expires: S+365, Routine
BUN
Expected: S+21 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+21 Approximate, Expires: S+365, Routine
CALCIUM
Expected: S+21 Approximate, Expires: S+365, Routine
ALBUMIN
Expected: S+21 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+21 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+21 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+21 Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S+21 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+21 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
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Zztestonc,PedsBeiber [2668824]
11/13/2017 9:46:12 AM Page 7 of 9
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

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 ULN.
Nursing Procedure, Assessment and Monitoring
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
sodium chloride 0.9 % infusion 500 mL
at 250-500 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
POST CISPLATIN HYDRATION. Delete if not needed.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
CISplatin (PLATINOL) 100 mg/m2 in sodium chloride 0.9 % 1,000 mL bag
100 mg/m2, Intravenous, ONCE, 1 dose Starting when released
For 60 to 90 minutes.
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
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Zztestonc,PedsBeiber [2668824]
11/13/2017 9:46:12 AM Page 8 of 9
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

DAY 22 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be
done locally), Electrolytes, BUN, Creatinine, Calcium, Alkaline Phosphatase, AST, Albumin, Magnesium,
Glucose, and Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT:  CISplatin for 240 minutes.
Lab Only - Day 10, Cycle 3 –  Planned for 1/3/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Head and Neck Cancer (Adjuvant/Advanced); THERAPY: CISplatin 100 mg/m2 IV on Day 1 concurrent with
radiotherapy; CYCLE LENGTH: 21 days; COURSE:  3 cycles or until end of radiotherapy.
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, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+9 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,PedsBeiber [2668824]
11/13/2017 9:46:12 AM Page 9 of 9
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org