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

/clinical/cckm-tools/content/beacon-protocols/lung/name-96929-en.cckm

201611333

page

100

UWHC,UWMF,

Tools,

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

CSC Lung Carboplatin(21D:1) Gemcitabine(21D:1,8) VER 10-3-16 (HL 56)

CSC Lung Carboplatin(21D:1) Gemcitabine(21D:1,8) VER 10-3-16 (HL 56) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Lung


CSC LUNG CARBOPLATIN(21D:1)/GEMCITABINE(21D:1,8) VER: 10-3-16 – Properties
Pre-Cycle – 11/21/2016 through 11/27/2016 (7 days), Planned
Day 1, Pre-Cycle – Planned for 11/21/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Adjuvant/Advanced); THERAPY: gemcitabine 1250 mg/m2 IV Day 1 and 8; CARBOplatin
(AUC=5) IV Day 1; CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S Approximate, Expires-S+365, Routine
BUN
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, 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
Take Home Medications
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
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed., 8 mg, Disp-30 tab, R-5, EVERY 8 HOURS PRN starting S
Cycle 1 – 11/28/2016 through 12/18/2016 (21 days), Planned
Day 1, Cycle 1 – Planned for 11/28/2016
Treatment Plan Information
Reference Information (1)
NON-SMALL CELL LUNG CANCER: Sederholm, C., et al. J Clin Onc 2005;23:8380-88.
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Adjuvant/Advanced); THERAPY: gemcitabine 1250 mg/m2 IV Day 1 and 8; CARBOplatin
(AUC=5) IV Day 1; CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles.
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ZZtestonc,Andrew [2428787]
11/28/2016 1:41:36 PM Page 1 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@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: 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 75K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
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ZZtestonc,Andrew [2428787]
11/28/2016 1:41:36 PM Page 2 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Medications
gemcitabine (GEMZAR) 2,238 mg in sodium chloride 0.9 % 100 mL bag
2,238 mg (rounded from 2,237.5 mg = 1,250 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
(Target AUC = 5), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes. Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient should be
treated in a location to optimize emergency care. See emergency medications.
Follow-Up
DAY 8 FOLLOW-UP
LABS:CBC, ANC (DIFF if done locally); CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 60 minutes.
DAY 15 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 and Total Bilirubin; CHEMOTHERAPY ROOM
APPOINTMENT: gemcitabine and CARBOplatin for 120 minutes.
Day 8, Cycle 1 – Planned for 12/5/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Adjuvant/Advanced); THERAPY: gemcitabine 1250 mg/m2 IV Day 1 and 8; CARBOplatin
(AUC=5) IV Day 1; CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
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,Andrew [2428787]
11/28/2016 1:41:36 PM Page 3 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
gemcitabine (GEMZAR) 2,238 mg in sodium chloride 0.9 % 100 mL bag
2,238 mg (rounded from 2,237.5 mg = 1,250 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 1 – Planned for 12/12/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Adjuvant/Advanced); THERAPY: gemcitabine 1250 mg/m2 IV Day 1 and 8; CARBOplatin
(AUC=5) IV Day 1; CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 12/19/2016 through 1/8/2017 (21 days), Planned
Day 1, Cycle 2 – Planned for 12/19/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Adjuvant/Advanced); THERAPY: gemcitabine 1250 mg/m2 IV Day 1 and 8; CARBOplatin
(AUC=5) IV Day 1; CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
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ZZtestonc,Andrew [2428787]
11/28/2016 1:41:36 PM Page 4 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+14 Approximate, Expires-S+365, Routine
BUN
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+14 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
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ZZtestonc,Andrew [2428787]
11/28/2016 1:41:36 PM Page 5 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
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
gemcitabine (GEMZAR) 2,238 mg in sodium chloride 0.9 % 100 mL bag
2,238 mg (rounded from 2,237.5 mg = 1,250 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
(Target AUC = 5), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes. Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient should be
treated in a location to optimize emergency care. See emergency medications.
Follow-Up
DAY 8 FOLLOW-UP
LABS:CBC, ANC (DIFF if done locally); CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 60 minutes.
DAY 15 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 and Total Bilirubin; CHEMOTHERAPY ROOM
APPOINTMENT: gemcitabine and CARBOplatin for 120 minutes.
Day 8, Cycle 2 – Planned for 12/26/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Adjuvant/Advanced); THERAPY: gemcitabine 1250 mg/m2 IV Day 1 and 8; CARBOplatin
(AUC=5) IV Day 1; CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
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ZZtestonc,Andrew [2428787]
11/28/2016 1:41:36 PM Page 6 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
gemcitabine (GEMZAR) 2,238 mg in sodium chloride 0.9 % 100 mL bag
2,238 mg (rounded from 2,237.5 mg = 1,250 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 2 – Planned for 1/2/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Adjuvant/Advanced); THERAPY: gemcitabine 1250 mg/m2 IV Day 1 and 8; CARBOplatin
(AUC=5) IV Day 1; CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 – 1/9/2017 through 1/29/2017 (21 days), Planned
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ZZtestonc,Andrew [2428787]
11/28/2016 1:41:36 PM Page 7 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Day 1, Cycle 3 – Planned for 1/9/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Adjuvant/Advanced); THERAPY: gemcitabine 1250 mg/m2 IV Day 1 and 8; CARBOplatin
(AUC=5) IV Day 1; CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+14 Approximate, Expires-S+365, Routine
BUN
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+14 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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ZZtestonc,Andrew [2428787]
11/28/2016 1:41:36 PM Page 8 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
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
gemcitabine (GEMZAR) 2,238 mg in sodium chloride 0.9 % 100 mL bag
2,238 mg (rounded from 2,237.5 mg = 1,250 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
(Target AUC = 5), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes. Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient should be
treated in a location to optimize emergency care. See emergency medications.
Follow-Up
DAY 8 FOLLOW-UP
LABS:CBC, ANC (DIFF if done locally); CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 60 minutes.
DAY 15 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 and Total Bilirubin; CHEMOTHERAPY ROOM
APPOINTMENT: gemcitabine and CARBOplatin for 120 minutes.
Day 8, Cycle 3 – Planned for 1/16/2017
Treatment Plan Information
Treatment Plan Summary
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ZZtestonc,Andrew [2428787]
11/28/2016 1:41:36 PM Page 9 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DISEASE: Non-Small Cell Lung Cancer (Adjuvant/Advanced); THERAPY: gemcitabine 1250 mg/m2 IV Day 1 and 8; CARBOplatin
(AUC=5) IV Day 1; CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
gemcitabine (GEMZAR) 2,238 mg in sodium chloride 0.9 % 100 mL bag
2,238 mg (rounded from 2,237.5 mg = 1,250 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 3 – Planned for 1/23/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Adjuvant/Advanced); THERAPY: gemcitabine 1250 mg/m2 IV Day 1 and 8; CARBOplatin
(AUC=5) IV Day 1; CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles.
IV Access
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ZZtestonc,Andrew [2428787]
11/28/2016 1:41:36 PM Page 10 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 – 1/30/2017 through 2/19/2017 (21 days), Planned
Day 1, Cycle 4 – Planned for 1/30/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Adjuvant/Advanced); THERAPY: gemcitabine 1250 mg/m2 IV Day 1 and 8; CARBOplatin
(AUC=5) IV Day 1; CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+14 Approximate, Expires-S+365, Routine
BUN
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+14 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
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ZZtestonc,Andrew [2428787]
11/28/2016 1:41:36 PM Page 11 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 75K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
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
gemcitabine (GEMZAR) 2,238 mg in sodium chloride 0.9 % 100 mL bag
2,238 mg (rounded from 2,237.5 mg = 1,250 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
(Target AUC = 5), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes. Hypersensitivity reaction to CARBOplatin 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,Andrew [2428787]
11/28/2016 1:41:36 PM Page 12 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Follow-Up
DAY 8 FOLLOW-UP
LABS:CBC, ANC (DIFF if done locally); CHEMOTHERAPY ROOM APPOINTMENT: gemcitabine for 60 minutes.
DAY 15 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 and Total Bilirubin; CHEMOTHERAPY ROOM
APPOINTMENT: gemcitabine and CARBOplatin for 120 minutes.
Day 8, Cycle 4 – Planned for 2/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Adjuvant/Advanced); THERAPY: gemcitabine 1250 mg/m2 IV Day 1 and 8; CARBOplatin
(AUC=5) IV Day 1; CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
gemcitabine (GEMZAR) 2,238 mg in sodium chloride 0.9 % 100 mL bag
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ZZtestonc,Andrew [2428787]
11/28/2016 1:41:36 PM Page 13 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

2,238 mg (rounded from 2,237.5 mg = 1,250 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 4 – Planned for 2/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Adjuvant/Advanced); THERAPY: gemcitabine 1250 mg/m2 IV Day 1 and 8; CARBOplatin
(AUC=5) IV Day 1; CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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ZZtestonc,Andrew [2428787]
11/28/2016 1:41:36 PM Page 14 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org