/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-96935-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 Cisplatin(21D:1) Etoposide(21D:1,(Oral)2,3) VER 10-3-16 (HL 350)

CSC Lung Cisplatin(21D:1) Etoposide(21D:1,(Oral)2,3) VER 10-3-16 (HL 350) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Lung


CSC LUNG CISPLATIN(21D:1)/ETOPOSIDE(21D:1,(ORAL)2,3) 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: Small Cell Lung Cancer (Adjuvant/Advanced); THERAPY: CISplatin 60 mg/m2 IV Day 1, etoposide 120 mg/m2 IV Day 1,
etoposide 120 mg/m2 by mouth twice daily on Day 2 and 3; CYCLE LENGTH: 21 days; COURSE: 4 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
MAGNESIUM
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
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, Local Printer
Cycle 1 – 11/28/2016 through 12/18/2016 (21 days), Planned
Day 1, Cycle 1 – Planned for 11/28/2016
Treatment Plan Information
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ZZtestonc,Andrew [2428787]
11/28/2016 2:19:48 PM Page 1 of 11
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Reference Information (1)
SMALL CELL LUNG CANCER: Sundstrom, et al. J Clin Oncol,2002;20:4665-72.
Treatment Plan Summary
DISEASE: Small Cell Lung Cancer (Adjuvant/Advanced); THERAPY: CISplatin 60 mg/m2 IV Day 1, etoposide 120 mg/m2 IV Day 1,
etoposide 120 mg/m2 by mouth twice daily on Day 2 and 3; CYCLE LENGTH: 21 days; COURSE: 4 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 1000/µL or Platelets less than 100K/µL
Nursing Procedure, Assessment and Monitoring
Measure Intake And Output
SEE COMMENTS Starting when released Until Specified
If IV intake is greater than 2000 mL and urine output is less than 500 mL, give furosemide. See Conditional Orders section.
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.
Supplemental Electrolytes
Evaluate patient’s labs. If additional additives are required, order outside of the treatment plan with administration instructions
"Pharmacist to add to intravenous fluids".
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) 107 mg in sodium chloride 0.9 % 1,000 mL bag
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ZZtestonc,Andrew [2428787]
11/28/2016 2:19:48 PM Page 2 of 11
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

107 mg (rounded from 107.4 mg = 60 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60-90 minutes.
etoposide (VEPESID) 215 mg in sodium chloride 0.9 % 500 mL NSS bag
215 mg (rounded from 214.8 mg = 120 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): etoposide
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.
Take Home Medications
etoposide (VEPESID) 50 MG cap
Take 4 caps by mouth 2 times daily for 2 days. Take only on Day 2 and 3 of each cycle., 200 mg (rounded from 214.8 mg = 120
mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S ending after 4 doses
Follow-Up
DAY 10 FOLLOW-UP
LABS:CBC, ANC (DIFF if 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, Magnesium; CHEMOTHERAPY
ROOM APPOINTMENT: CISplatin and etoposide infusion for 210 minutes.
Lab Only - Day 10, Cycle 1 – Planned for 12/7/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Small Cell Lung Cancer (Adjuvant/Advanced); THERAPY: CISplatin 60 mg/m2 IV Day 1, etoposide 120 mg/m2 IV Day 1,
etoposide 120 mg/m2 by mouth twice daily on Day 2 and 3; CYCLE LENGTH: 21 days; COURSE: 4 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 WITH DIFFERENTIAL
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 – 12/19/2016 through 1/8/2017 (21 days), Planned
Day 1, Cycle 2 – Planned for 12/19/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Small Cell Lung Cancer (Adjuvant/Advanced); THERAPY: CISplatin 60 mg/m2 IV Day 1, etoposide 120 mg/m2 IV Day 1,
etoposide 120 mg/m2 by mouth twice daily on Day 2 and 3; CYCLE LENGTH: 21 days; COURSE: 4 cycles.
Consent
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ZZtestonc,Andrew [2428787]
11/28/2016 2:19:48 PM Page 3 of 11
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@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
MAGNESIUM
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 1000/µL or Platelets less than 100K/µL
Nursing Procedure, Assessment and Monitoring
Measure Intake And Output
SEE COMMENTS Starting when released Until Specified
If IV intake is greater than 2000 mL and urine output is less than 500 mL, give furosemide. See Conditional Orders section.
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
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ZZtestonc,Andrew [2428787]
11/28/2016 2:19:48 PM Page 4 of 11
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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.
Supplemental Electrolytes
Evaluate patient’s labs. If additional additives are required, order outside of the treatment plan with administration instructions
"Pharmacist to add to intravenous fluids".
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) 107 mg in sodium chloride 0.9 % 1,000 mL bag
107 mg (rounded from 107.4 mg = 60 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60-90 minutes.
etoposide (VEPESID) 215 mg in sodium chloride 0.9 % 500 mL NSS bag
215 mg (rounded from 214.8 mg = 120 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): etoposide
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.
Take Home Medications
etoposide (VEPESID) 50 MG cap
Take 4 caps by mouth 2 times daily for 2 days. Take only on Day 2 and 3 of each cycle., 200 mg (rounded from 214.8 mg = 120
mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S ending after 4 doses
Follow-Up
DAY 10 FOLLOW-UP
LABS:CBC, ANC (DIFF if 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, Magnesium; CHEMOTHERAPY
ROOM APPOINTMENT: CISplatin and etoposide infusion for 210 minutes.
Lab Only - Day 10, Cycle 2 – Planned for 12/28/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Small Cell Lung Cancer (Adjuvant/Advanced); THERAPY: CISplatin 60 mg/m2 IV Day 1, etoposide 120 mg/m2 IV Day 1,
etoposide 120 mg/m2 by mouth twice daily on Day 2 and 3; CYCLE LENGTH: 21 days; COURSE: 4 cycles.
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/28/2016 2:19:48 PM Page 5 of 11
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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 – 1/9/2017 through 1/29/2017 (21 days), Planned
Day 1, Cycle 3 – Planned for 1/9/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Small Cell Lung Cancer (Adjuvant/Advanced); THERAPY: CISplatin 60 mg/m2 IV Day 1, etoposide 120 mg/m2 IV Day 1,
etoposide 120 mg/m2 by mouth twice daily on Day 2 and 3; CYCLE LENGTH: 21 days; COURSE: 4 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
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ZZtestonc,Andrew [2428787]
11/28/2016 2:19:48 PM Page 6 of 11
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

MAGNESIUM
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 1000/µL or Platelets less than 100K/µL
Nursing Procedure, Assessment and Monitoring
Measure Intake And Output
SEE COMMENTS Starting when released Until Specified
If IV intake is greater than 2000 mL and urine output is less than 500 mL, give furosemide. See Conditional Orders section.
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.
Supplemental Electrolytes
Evaluate patient’s labs. If additional additives are required, order outside of the treatment plan with administration instructions
"Pharmacist to add to intravenous fluids".
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) 107 mg in sodium chloride 0.9 % 1,000 mL bag
107 mg (rounded from 107.4 mg = 60 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60-90 minutes.
etoposide (VEPESID) 215 mg in sodium chloride 0.9 % 500 mL NSS bag
215 mg (rounded from 214.8 mg = 120 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): etoposide
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
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ZZtestonc,Andrew [2428787]
11/28/2016 2:19:48 PM Page 7 of 11
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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.
Take Home Medications
etoposide (VEPESID) 50 MG cap
Take 4 caps by mouth 2 times daily for 2 days. Take only on Day 2 and 3 of each cycle., 200 mg (rounded from 214.8 mg = 120
mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S ending after 4 doses
Follow-Up
DAY 10 FOLLOW-UP
LABS:CBC, ANC (DIFF if 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, Magnesium; CHEMOTHERAPY
ROOM APPOINTMENT: CISplatin and etoposide infusion for 210 minutes.
Lab Only - Day 10, Cycle 3 – Planned for 1/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Small Cell Lung Cancer (Adjuvant/Advanced); THERAPY: CISplatin 60 mg/m2 IV Day 1, etoposide 120 mg/m2 IV Day 1,
etoposide 120 mg/m2 by mouth twice daily on Day 2 and 3; CYCLE LENGTH: 21 days; COURSE: 4 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 – 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: Small Cell Lung Cancer (Adjuvant/Advanced); THERAPY: CISplatin 60 mg/m2 IV Day 1, etoposide 120 mg/m2 IV Day 1,
etoposide 120 mg/m2 by mouth twice daily on Day 2 and 3; CYCLE LENGTH: 21 days; COURSE: 4 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
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ZZtestonc,Andrew [2428787]
11/28/2016 2:19:48 PM Page 8 of 11
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL
Nursing Procedure, Assessment and Monitoring
Measure Intake And Output
SEE COMMENTS Starting when released Until Specified
If IV intake is greater than 2000 mL and urine output is less than 500 mL, give furosemide. See Conditional Orders section.
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.
Supplemental Electrolytes
Evaluate patient’s labs. If additional additives are required, order outside of the treatment plan with administration instructions
"Pharmacist to add to intravenous fluids".
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ZZtestonc,Andrew [2428787]
11/28/2016 2:19:48 PM Page 9 of 11
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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) 107 mg in sodium chloride 0.9 % 1,000 mL bag
107 mg (rounded from 107.4 mg = 60 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60-90 minutes.
etoposide (VEPESID) 215 mg in sodium chloride 0.9 % 500 mL NSS bag
215 mg (rounded from 214.8 mg = 120 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): etoposide
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.
Take Home Medications
etoposide (VEPESID) 50 MG cap
Take 4 caps by mouth 2 times daily for 2 days. Take only on Day 2 and 3 of each cycle., 200 mg (rounded from 214.8 mg = 120
mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S ending after 4 doses
Follow-Up
DAY 10 FOLLOW-UP
LABS:CBC, ANC (DIFF if 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, Magnesium; CHEMOTHERAPY
ROOM APPOINTMENT: CISplatin and etoposide infusion for 210 minutes.
Lab Only - Day 10, Cycle 4 – Planned for 2/8/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Small Cell Lung Cancer (Adjuvant/Advanced); THERAPY: CISplatin 60 mg/m2 IV Day 1, etoposide 120 mg/m2 IV Day 1,
etoposide 120 mg/m2 by mouth twice daily on Day 2 and 3; CYCLE LENGTH: 21 days; COURSE: 4 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
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ZZtestonc,Andrew [2428787]
11/28/2016 2:19:48 PM Page 10 of 11
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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 2:19:48 PM Page 11 of 11
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org