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201611333

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UWHC,UWMF,

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

CSC Lung Cisplatin(21D:1) Docetaxel(21D:1) VER 10-3-16 (HL 62)

CSC Lung Cisplatin(21D:1) Docetaxel(21D:1) VER 10-3-16 (HL 62) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Lung


CSC LUNG CISPLATIN(21D:1)/DOCETAXEL(21D:1) 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: DOCEtaxel 75 mg/m2 IV Day 1, CISplatin 75 mg/m2 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
MAGNESIUM
Expected-S Approximate, Expires-S+365, Routine
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
Starting the AM before chemo, take 2 tabs by mouth 2X daily for 3 days, then 2 tablets 1X daily for 2 days., Disp-50 tab, R-1, starting
S, Local Printer
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
prochlorperazine (COMPAZINE) 10 MG tab
Take 1 tab by mouth every 6 hours as needed (For nausea)., 10 mg, Disp-30 tab, R-5, EVERY 6 HOURS PRN starting S
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed for nausea/vomiting., 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
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ZZtestonc,Andrew [2428787]
11/28/2016 2:18:42 PM Page 1 of 12
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Day 1, Cycle 1 – Planned for 11/28/2016
Treatment Plan Information
Reference Information (1)
NON-SMALL CELL LUNG CANCER: Belani, C.P., et al. Clin Lung Cancer 1999;1: 144-50.
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Adjuvant/Advanced); THERAPY: DOCEtaxel 75 mg/m2 IV Day 1, CISplatin 75 mg/m2 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.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelet, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL
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.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity to DOCEtaxel can occur. For first and second dose, patient should be treated in a location to optimize emergency
care. See Emergency Medications.
** Rush dextrose primed line with 18mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the 1st and 2nd dose of docetaxel administration and then every 30 minutes for any
subsequent doses if previous doses tolerated.
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
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ZZtestonc,Andrew [2428787]
11/28/2016 2:18:42 PM Page 2 of 12
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 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
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN Starting when released Until Discontinued, If PO not taken at home.
For use in patients who did not take dexamethasone at home.
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
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
DOCEtaxel (TAXOTERE) 134 mg in dextrose 5 % 250 mL non-PVC bag
134 mg (rounded from 134.25 mg = 75 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 60 minutes. Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications. In non-PVC bag. Infuse through non PVC tubing.
CISplatin (PLATINOL) 134 mg in sodium chloride 0.9 % 1,000 mL bag
134 mg (rounded from 134.25 mg = 75 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 30 to 60 minutes.
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Take Home Medications
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
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 done locally), Electrolytes,
BUN, Creatinine, Calcium, Alkaline Phosphatase, AST, Albumin and Total Bilirubin, Magnesium;
CHEMOTHERAPY ROOM APPOINTMENT: DOCEtaxel and CISplatin for 180 minutes.
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ZZtestonc,Andrew [2428787]
11/28/2016 2:18:42 PM Page 3 of 12
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Lab Only - Day 10, Cycle 1 – Planned for 12/7/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Adjuvant/Advanced); THERAPY: DOCEtaxel 75 mg/m2 IV Day 1, CISplatin 75 mg/m2 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+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 12/19/2016 through 1/8/2017 (21 days), Planned
Day 1, Cycle 2 – Planned for 12/19/2016
Treatment Plan Information
Reference Information (1)
NON-SMALL CELL LUNG CANCER: Belani, C.P., et al. Clin Lung Cancer 1999;1: 144-50.
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Adjuvant/Advanced); THERAPY: DOCEtaxel 75 mg/m2 IV Day 1, CISplatin 75 mg/m2 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+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
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ZZtestonc,Andrew [2428787]
11/28/2016 2:18:42 PM Page 4 of 12
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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 and resulted: WBC, ANC, Platelets and Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL
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.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity to DOCEtaxel can occur. For first and second dose, patient should be treated in a location to optimize emergency
care. See Emergency Medications.
** Rush dextrose primed line with 18mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the 1st and 2nd dose of docetaxel administration and then every 30 minutes for any
subsequent doses if previous doses tolerated.
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 2:18:42 PM Page 5 of 12
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
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
DOCEtaxel (TAXOTERE) 134 mg in dextrose 5 % 250 mL non-PVC bag
134 mg (rounded from 134.25 mg = 75 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 60 minutes. Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications. In non-PVC bag. Infuse through non PVC tubing.
CISplatin (PLATINOL) 134 mg in sodium chloride 0.9 % 1,000 mL bag
134 mg (rounded from 134.25 mg = 75 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 30 to 60 minutes.
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Electrolytes,
BUN, Creatinine, Calcium, Alkaline Phosphatase, AST, Albumin and Total Bilirubin, Magnesium;
CHEMOTHERAPY ROOM APPOINTMENT: DOCEtaxel and CISplatin for 180 minutes.
Lab Only - Day 10, Cycle 2 – Planned for 12/28/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Adjuvant/Advanced); THERAPY: DOCEtaxel 75 mg/m2 IV Day 1, CISplatin 75 mg/m2 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
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ZZtestonc,Andrew [2428787]
11/28/2016 2:18:42 PM Page 6 of 12
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+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: Non-Small Cell Lung Cancer (Adjuvant/Advanced); THERAPY: DOCEtaxel 75 mg/m2 IV Day 1, CISplatin 75 mg/m2 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+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
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ZZtestonc,Andrew [2428787]
11/28/2016 2:18:42 PM Page 7 of 12
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelet Count and Serum Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL
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.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity to DOCEtaxel can occur. For first and second dose, patient should be treated in a location to optimize emergency
care. See Emergency Medications.
** Rush dextrose primed line with 18mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Vital Signs
EVERY 30 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the 1st and 2nd dose of docetaxel administration and then every 30 minutes for any
subsequent doses if previous doses tolerated.
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
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
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ZZtestonc,Andrew [2428787]
11/28/2016 2:18:42 PM Page 8 of 12
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
DOCEtaxel (TAXOTERE) 134 mg in dextrose 5 % 250 mL non-PVC bag
134 mg (rounded from 134.25 mg = 75 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 60 minutes. Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications. In non-PVC bag. Infuse through non PVC tubing.
CISplatin (PLATINOL) 134 mg in sodium chloride 0.9 % 1,000 mL bag
134 mg (rounded from 134.25 mg = 75 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 30 to 60 minutes.
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Electrolytes,
BUN, Creatinine, Calcium, Alkaline Phosphatase, AST, Albumin and Total Bilirubin, Magnesium;
CHEMOTHERAPY ROOM APPOINTMENT: DOCEtaxel and CISplatin for 180 minutes.
Lab Only - Day 10, Cycle 3 – Planned for 1/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Adjuvant/Advanced); THERAPY: DOCEtaxel 75 mg/m2 IV Day 1, CISplatin 75 mg/m2 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+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
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ZZtestonc,Andrew [2428787]
11/28/2016 2:18:42 PM Page 9 of 12
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: DOCEtaxel 75 mg/m2 IV Day 1,
CISplatin 75 mg/m2 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+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 and resulted: WBC, ANC, Platelet Count and Serum Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL
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.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity to DOCEtaxel can occur. For first and second dose, patient should be treated in a location to optimize emergency
care. See Emergency Medications.
** Rush dextrose primed line with 18mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
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ZZtestonc,Andrew [2428787]
11/28/2016 2:18:42 PM Page 10 of 12
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Vital Signs
EVERY 30 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the 1st and 2nd dose of docetaxel administration and then every 30
minutes for any subsequent doses if previous doses tolerated.
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
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
DOCEtaxel (TAXOTERE) 134 mg in dextrose 5 % 250 mL non-PVC bag
134 mg (rounded from 134.25 mg = 75 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 60 minutes. Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications. In non-PVC bag. Infuse through non PVC tubing.
CISplatin (PLATINOL) 134 mg in sodium chloride 0.9 % 1,000 mL bag
134 mg (rounded from 134.25 mg = 75 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 30 to 60 minutes.
Conditional Orders
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ZZtestonc,Andrew [2428787]
11/28/2016 2:18:42 PM Page 11 of 12
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Electrolytes,
BUN, Creatinine, Calcium, Alkaline Phosphatase, AST, Albumin and Total Bilirubin, Magnesium;
CHEMOTHERAPY ROOM APPOINTMENT: DOCEtaxel and CISplatin for 180 minutes.
Lab Only - Day 10, Cycle 4 – Planned for 2/8/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Adjuvant/Advanced); THERAPY: DOCEtaxel 75 mg/m2 IV Day 1, CISplatin 75 mg/m2 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+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,Andrew [2428787]
11/28/2016 2:18:42 PM Page 12 of 12
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org