/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-96932-en.cckm

20170127

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) Pemetrexed(21D:1) VER 1-25-17 (HL 49)

CSC Lung Carboplatin(21D:1) Pemetrexed(21D:1) VER 1-25-17 (HL 49) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Lung


CSC LUNG CARBOPLATIN(21D:1)/PEMETREXED(21D:1) VER: 1-25-17 – Properties
Pre-Cycle – 1/18/2017 through 1/24/2017 (7 days), Planned
Day 1, Pre-Cycle – Planned for 1/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE:Malignant Pleural Mesothelioma (Adjuvant/Advanced); THERAPY: pemetrexed 500 mg/m2 IV Day 1, CARBOplatin
(AUC=5) IV Day 1, folic acid at least 300 mcg orally once daily to begin at least 1 week prior to pemetrexed and continue for 3
weeks after last dose of pemetrexed, cyanocobalamin (Vitamin B12) 1mg IM once every 9 weeks to begin at least 1 week prior to
pemetrexed and to continue until pemetrexed is discontinued; CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles.
Treatment Plan Summary (2)
DISEASE: Non-Small Cell Lung Cancer (Adjuvant/Advanced); THERAPY: pemetrexed 500 mg/m2 IV Day 1, CARBOplatin
(AUC=5) IV Day 1, folic acid at least 300 mcg orally once daily to begin at least 1 week prior to pemetrexed and continue for 3
weeks after last dose of pemetrexed, cyanocobalamin (Vitamin B12) 1mg IM once every 9 weeks to begin at least 1 week prior to
pemetrexed and to continue until pemetrexed is discontinued; 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 1 tab twice daily the day prior, day of and day after chemo, then 2 tabs once daily X 2 days, Disp-48 tab, R-1, starting S, Local
Printer
To prevent pemetrexed rash and post chemotherapy nausea
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
folic acid (FOLVITE) 1 MG tab
Take 1 tab by mouth one time daily., 1 mg, Disp-30 tab, R-11, 1 X DAILY starting S, Local Printer
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Zztestonc,Jeff J [2507481]
1/25/2017 8:40:52 AM Page 1 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

Cycle 1 – 1/25/2017 through 2/14/2017 (21 days), Planned
Day 1, Cycle 1 – Planned for 1/25/2017
Treatment Plan Information
Reference Information (1)
NON-SMALL CELL LUNG CANCER - Zinner R, et al. Cancer 2005;104:2449-56.
Reference Information (2)
MESOTHELIOMA - Ceresoli G. J Clin Oncol (2006); 24:1443-8.
Treatment Plan Summary
DISEASE:Malignant Pleural Mesothelioma (Adjuvant/Advanced); THERAPY: pemetrexed 500 mg/m2 IV Day 1, CARBOplatin
(AUC=5) IV Day 1, folic acid at least 300 mcg orally once daily to begin at least 1 week prior to pemetrexed and continue for 3
weeks after last dose of pemetrexed, cyanocobalamin (Vitamin B12) 1mg IM once every 9 weeks to begin at least 1 week prior to
pemetrexed and to continue until pemetrexed is discontinued; CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles.
Treatment Plan Summary (2)
DISEASE: Non-Small Cell Lung Cancer (Adjuvant/Advanced); THERAPY: pemetrexed 500 mg/m2 IV Day 1, CARBOplatin
(AUC=5) IV Day 1, folic acid at least 300 mcg orally once daily to begin at least 1 week prior to pemetrexed and continue for 3
weeks after last dose of pemetrexed, cyanocobalamin (Vitamin B12) 1mg IM once every 9 weeks to begin at least 1 week prior to
pemetrexed and to continue until pemetrexed is discontinued; 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.
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 1,000/µL or Platelets less than or equal to 100K/µL or Creatinine
Clearance less than 45 mL/minute or any results not within normal limits.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone premedication and document in a progress note. Notify authorizing prescriber if patient
has not taken as prescribed.
Verify Medication(s) Taken at Home (2)
Verify that patient has taken folic acid and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Verify Medication(s) Taken at Home (3)
Verify that patient has received cyanocobalamin and document in a progress note. Notify authorizing prescriber if patient has not
received medication as prescribed.
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
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Zztestonc,Jeff J [2507481]
1/25/2017 8:40:52 AM Page 2 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
dexamethasone (DECADRON) 10 MG/ML injection 8 mg
8 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.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer 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
pemetrexed (ALIMTA) 1,815 mg in sodium chloride 0.9 % 100 mL bag
1,815 mg (500 mg/m2 × 3.63 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes.
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 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 and Total Bilirubin; CHEMOTHERAPY ROOM
APPOINTMENT: CARBOplatin and pemetrexed for 120 minutes.
Lab Only - Day 10, Cycle 1 – Planned for 2/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE:Malignant Pleural Mesothelioma (Adjuvant/Advanced); THERAPY: pemetrexed 500 mg/m2 IV Day 1, CARBOplatin
(AUC=5) IV Day 1, folic acid at least 300 mcg orally once daily to begin at least 1 week prior to pemetrexed and continue for 3
weeks after last dose of pemetrexed, cyanocobalamin (Vitamin B12) 1mg IM once every 9 weeks to begin at least 1 week prior to
pemetrexed and to continue until pemetrexed is discontinued; CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles.
Treatment Plan Summary (2)
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Zztestonc,Jeff J [2507481]
1/25/2017 8:40:52 AM Page 3 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

DISEASE: Non-Small Cell Lung Cancer (Adjuvant/Advanced); THERAPY: pemetrexed 500 mg/m2 IV Day 1, CARBOplatin
(AUC=5) IV Day 1, folic acid at least 300 mcg orally once daily to begin at least 1 week prior to pemetrexed and continue for 3
weeks after last dose of pemetrexed, cyanocobalamin (Vitamin B12) 1mg IM once every 9 weeks to begin at least 1 week prior to
pemetrexed and to continue until pemetrexed is discontinued; 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+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 – 2/15/2017 through 3/7/2017 (21 days), Planned
Day 1, Cycle 2 – Planned for 2/15/2017
Treatment Plan Information
Reference Information (1)
NON-SMALL CELL LUNG CANCER - Zinner R, et al. Cancer 2005;104:2449-56.
Reference Information (2)
MESOTHELIOMA - Ceresoli G. J Clin Oncol (2006); 24:1443-8.
Treatment Plan Summary
DISEASE:Malignant Pleural Mesothelioma (Adjuvant/Advanced); THERAPY: pemetrexed 500 mg/m2 IV Day 1, CARBOplatin
(AUC=5) IV Day 1, folic acid at least 300 mcg orally once daily to begin at least 1 week prior to pemetrexed and continue for 3
weeks after last dose of pemetrexed, cyanocobalamin (Vitamin B12) 1mg IM once every 9 weeks to begin at least 1 week prior to
pemetrexed and to continue until pemetrexed is discontinued; CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles.
Treatment Plan Summary (2)
DISEASE: Non-Small Cell Lung Cancer (Adjuvant/Advanced); THERAPY: pemetrexed 500 mg/m2 IV Day 1, CARBOplatin
(AUC=5) IV Day 1, folic acid at least 300 mcg orally once daily to begin at least 1 week prior to pemetrexed and continue for 3
weeks after last dose of pemetrexed, cyanocobalamin (Vitamin B12) 1mg IM once every 9 weeks to begin at least 1 week prior to
pemetrexed and to continue until pemetrexed is discontinued; 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+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
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Zztestonc,Jeff J [2507481]
1/25/2017 8:40:52 AM Page 4 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

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
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 1,000/µL or Platelets less than or equal to 100K/µL or Creatinine
Clearance less than 45 mL/minute or any results not within normal limits.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone premedication and document in a progress note. Notify authorizing prescriber if patient
has not taken as prescribed.
Verify Medication(s) Taken at Home (2)
Verify that patient has taken folic acid 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 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
Administer prior to chemotherapy.
Emergency Medications
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Zztestonc,Jeff J [2507481]
1/25/2017 8:40:52 AM Page 5 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

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
pemetrexed (ALIMTA) 1,815 mg in sodium chloride 0.9 % 100 mL bag
1,815 mg (500 mg/m2 × 3.63 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes.
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 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 and Total Bilirubin; CHEMOTHERAPY ROOM
APPOINTMENT: CARBOplatin and pemetrexed for 120 minutes; administration of cyanocobalamin.
Lab Only - Day 10, Cycle 2 – Planned for 2/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE:Malignant Pleural Mesothelioma (Adjuvant/Advanced); THERAPY: pemetrexed 500 mg/m2 IV Day 1, CARBOplatin
(AUC=5) IV Day 1, folic acid at least 300 mcg orally once daily to begin at least 1 week prior to pemetrexed and continue for 3
weeks after last dose of pemetrexed, cyanocobalamin (Vitamin B12) 1mg IM once every 9 weeks to begin at least 1 week prior to
pemetrexed and to continue until pemetrexed is discontinued; CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles.
Treatment Plan Summary (2)
DISEASE: Non-Small Cell Lung Cancer (Adjuvant/Advanced); THERAPY: pemetrexed 500 mg/m2 IV Day 1, CARBOplatin
(AUC=5) IV Day 1, folic acid at least 300 mcg orally once daily to begin at least 1 week prior to pemetrexed and continue for 3
weeks after last dose of pemetrexed, cyanocobalamin (Vitamin B12) 1mg IM once every 9 weeks to begin at least 1 week prior to
pemetrexed and to continue until pemetrexed is discontinued; 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+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,Jeff J [2507481]
1/25/2017 8:40:52 AM Page 6 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

Cycle 3 – 3/8/2017 through 3/28/2017 (21 days), Planned
Day 1, Cycle 3 – Planned for 3/8/2017
Treatment Plan Information
Reference Information (1)
NON-SMALL CELL LUNG CANCER - Zinner R, et al. Cancer 2005;104:2449-56.
Reference Information (2)
MESOTHELIOMA - Ceresoli G. J Clin Oncol (2006); 24:1443-8.
Treatment Plan Summary
DISEASE:Malignant Pleural Mesothelioma (Adjuvant/Advanced) / Non-Small Cell Lung Cancer (Adjuvant/Advanced); THERAPY:
CARBOplatin (AUC=5) IV Day 1, pemetrexed 500 mg/m2 IV Day 1, folic acid at least 300 mcg orally once daily to begin at least 1
week prior to pemetrexed and continue for 3 weeks after last dose of pemetrexed, cyanocobalamin (Vitamin B12) 1mg IM once
every 9 weeks to begin at least 1 week prior to pemetrexed and to continue until pemetrexed is discontinued; 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+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
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 1,000/µL or Platelets less than or equal to 100K/µL or Creatinine
Clearance less than 45 mL/minute or any results not within normal limits.
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Zztestonc,Jeff J [2507481]
1/25/2017 8:40:52 AM Page 7 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone premedication and document in a progress note. Notify authorizing prescriber if patient
has not taken as prescribed.
Verify Medication(s) Taken at Home (2)
Verify that patient has taken folic acid 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 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
Administer 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
cyanocobalamin (RUBIMIN) injection 1,000 mcg
1,000 mcg, Intramuscular, ONCE, 1 dose Starting when released
pemetrexed (ALIMTA) 1,815 mg in sodium chloride 0.9 % 100 mL bag
1,815 mg (500 mg/m2 × 3.63 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes.
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
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Zztestonc,Jeff J [2507481]
1/25/2017 8:40:52 AM Page 8 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

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 and Total Bilirubin;
CHEMOTHERAPY ROOM APPOINTMENT: CARBOplatin and pemetrexed for 120 minutes.
Lab Only - Day 10, Cycle 3 – Planned for 3/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE:Malignant Pleural Mesothelioma (Adjuvant/Advanced); THERAPY: pemetrexed 500 mg/m2 IV Day 1, CARBOplatin
(AUC=5) IV Day 1, folic acid at least 300 mcg orally once daily to begin at least 1 week prior to pemetrexed and continue for 3
weeks after last dose of pemetrexed, cyanocobalamin (Vitamin B12) 1mg IM once every 9 weeks to begin at least 1 week prior to
pemetrexed and to continue until pemetrexed is discontinued; CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles.
Treatment Plan Summary (2)
DISEASE: Non-Small Cell Lung Cancer (Adjuvant/Advanced); THERAPY: pemetrexed 500 mg/m2 IV Day 1, CARBOplatin
(AUC=5) IV Day 1, folic acid at least 300 mcg orally once daily to begin at least 1 week prior to pemetrexed and continue for 3
weeks after last dose of pemetrexed, cyanocobalamin (Vitamin B12) 1mg IM once every 9 weeks to begin at least 1 week prior to
pemetrexed and to continue until pemetrexed is discontinued; 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+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 4 – 3/29/2017 through 4/18/2017 (21 days), Planned
Day 1, Cycle 4 – Planned for 3/29/2017
Treatment Plan Information
Reference Information (1)
NON-SMALL CELL LUNG CANCER - Zinner R, et al. Cancer 2005;104:2449-56.
Reference Information (2)
MESOTHELIOMA - Ceresoli G. J Clin Oncol (2006); 24:1443-8.
Treatment Plan Summary
DISEASE:Malignant Pleural Mesothelioma (Adjuvant/Advanced); THERAPY: pemetrexed 500 mg/m2 IV Day 1, CARBOplatin
(AUC=5) IV Day 1, folic acid at least 300 mcg orally once daily to begin at least 1 week prior to pemetrexed and continue for 3
weeks after last dose of pemetrexed, cyanocobalamin (Vitamin B12) 1mg IM once every 9 weeks to begin at least 1 week prior to
pemetrexed and to continue until pemetrexed is discontinued; CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles.
Treatment Plan Summary (2)
DISEASE: Non-Small Cell Lung Cancer (Adjuvant/Advanced); THERAPY: pemetrexed 500 mg/m2 IV Day 1, CARBOplatin
(AUC=5) IV Day 1, folic acid at least 300 mcg orally once daily to begin at least 1 week prior to pemetrexed and continue for 3
weeks after last dose of pemetrexed, cyanocobalamin (Vitamin B12) 1mg IM once every 9 weeks to begin at least 1 week prior to
pemetrexed and to continue until pemetrexed is discontinued; CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles.
Consent
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Zztestonc,Jeff J [2507481]
1/25/2017 8:40:52 AM Page 9 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

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
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 1,000/µL or Platelets less than or equal to 100K/µL or Creatinine
Clearance less than 45 mL/minute or any results not within normal limits.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone premedication and document in a progress note. Notify authorizing prescriber if patient
has not taken as prescribed.
Verify Medication(s) Taken at Home (2)
Verify that patient has taken folic acid 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 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.
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Zztestonc,Jeff J [2507481]
1/25/2017 8:40:52 AM Page 10 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

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
Administer 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
pemetrexed (ALIMTA) 1,815 mg in sodium chloride 0.9 % 100 mL bag
1,815 mg (500 mg/m2 × 3.63 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes.
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 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 and Total Bilirubin;
CHEMOTHERAPY ROOM APPOINTMENT: CARBOplatin and pemetrexed for 120 minutes.
Lab Only - Day 10, Cycle 4 – Planned for 4/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE:Malignant Pleural Mesothelioma (Adjuvant/Advanced); THERAPY: pemetrexed 500 mg/m2 IV Day 1, CARBOplatin
(AUC=5) IV Day 1, folic acid at least 300 mcg orally once daily to begin at least 1 week prior to pemetrexed and continue for 3
weeks after last dose of pemetrexed, cyanocobalamin (Vitamin B12) 1mg IM once every 9 weeks to begin at least 1 week prior to
pemetrexed and to continue until pemetrexed is discontinued; CYCLE LENGTH: 21 days; COURSE: 4 to 6 cycles.
Treatment Plan Summary (2)
DISEASE: Non-Small Cell Lung Cancer (Adjuvant/Advanced); THERAPY: pemetrexed 500 mg/m2 IV Day 1, CARBOplatin
(AUC=5) IV Day 1, folic acid at least 300 mcg orally once daily to begin at least 1 week prior to pemetrexed and continue for 3
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Zztestonc,Jeff J [2507481]
1/25/2017 8:40:52 AM Page 11 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

weeks after last dose of pemetrexed, cyanocobalamin (Vitamin B12) 1mg IM once every 9 weeks to begin at least 1 week prior to
pemetrexed and to continue until pemetrexed is discontinued; 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+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,Jeff J [2507481]
1/25/2017 8:40:52 AM Page 12 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org