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201611333

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100

UWHC,UWMF,

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

CSC Lung Concurrent XRT Cisplatin(28D:1,8) Etoposide(28D:1-5) VER 10-3-16 (HL 55)

CSC Lung Concurrent XRT Cisplatin(28D:1,8) Etoposide(28D:1-5) VER 10-3-16 (HL 55) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Lung


CSC LUNG CONCURRENT XRT CISPLATIN(28D:1,8)/ETOPSIDE(28D:1-5) 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; THERAPY: CISplatin / etoposide for 2 cycles concurrent with radiation therapy. CISplatin
50mg/m2 IV on Days 1 and 8, etoposide 50 mg/m2 IV Days 1, 2, 3, 4 and 5, (Cycle 1 starts on Day 1 = first week of radiation
therapy and Cycle 2 starts on Day 29 = last week of radiation therapy); CYCLE LENGTH: 28 days; COURSE: 2 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
prochlorperazine (COMPAZINE) 10 MG tab
Take 1 tab by mouth every 6 hours as needed for nausea/vomiting., 10 mg, Disp-30 tab, R-5, EVERY 6 HOURS PRN starting S,
Local Printer
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed for nausea/vomiting. (Except Day 1 and 8), 8 mg, Disp-30 tab, R-5, EVERY 8 HOURS
PRN starting S, Local Printer
dexamethasone (DECADRON) 4 MG tab
Take 2 tabs by mouth one time daily. Take on Days 9, 10, and 11., 8 mg, Disp-12 tab, R-0, 1 X DAILY starting S, Local Printer
Cycle 1 – 11/28/2016 through 12/25/2016 (28 days), Planned
Day 1, Cycle 1 – Planned for 11/28/2016
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ZZtestonc,Andrew [2428787]
11/28/2016 2:32:00 PM Page 1 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Plan Information
Reference Information (1)
NON-SMALL CELL LUNG CANCER: Gandara, D.R., et al. J Clin Oncol 2003;21: 2004-10.
Reference Information (2)
NON-SMALL CELL LUNG CANCER: Hanna, N.H., Neubauer, M., Ansari, R., et al. J Clin Oncol 2007;25(18S):7512.
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer; THERAPY: CISplatin / etoposide for 2 cycles concurrent with radiation therapy. CISplatin
50mg/m2 IV on Days 1 and 8, etoposide 50 mg/m2 IV Days 1, 2, 3, 4 and 5, (Cycle 1 starts on Day 1 = first week of radiation
therapy and Cycle 2 starts on Day 29 = last week of radiation therapy); CYCLE LENGTH: 28 days; COURSE: 2 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
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
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ZZtestonc,Andrew [2428787]
11/28/2016 2:32:00 PM Page 2 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
Treatment Medications
CISplatin (PLATINOL) 90 mg in sodium chloride 0.9 % 1,000 mL bag
90 mg (rounded from 89.5 mg = 50 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60-90 minutes.
etoposide (VEPESID) 90 mg in sodium chloride 0.9 % 500 mL NSS bag
90 mg (rounded from 89.5 mg = 50 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
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 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: etoposide 60 minutes
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: etoposide 60 minutes
DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: etoposide 60 minutes
DAY 5 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: etoposide 60 minutes
DAY 8 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: CISplatin 120 minutes.
LABS: CBC, ANC (DIFF if to be done locally), Electrolytes, BUN, Creatinine, Calcium, Alkaline Phosphatase, AST, Albumin and
Total Bilirubin.
DAY 29 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 for 210 minutes.
Day 2, Cycle 1 – Planned for 11/29/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer; THERAPY: CISplatin / etoposide for 2 cycles concurrent with radiation therapy. CISplatin
50mg/m2 IV on Days 1 and 8, etoposide 50 mg/m2 IV Days 1, 2, 3, 4 and 5, (Cycle 1 starts on Day 1 = first week of radiation
therapy and Cycle 2 starts on Day 29 = last week of radiation therapy); CYCLE LENGTH: 28 days; COURSE: 2 cycles
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
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ZZtestonc,Andrew [2428787]
11/28/2016 2:32:00 PM Page 3 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
Treatment Medications
etoposide (VEPESID) 90 mg in sodium chloride 0.9 % 500 mL NSS bag
90 mg (rounded from 89.5 mg = 50 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
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 1 – Planned for 11/30/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer; THERAPY: CISplatin / etoposide for 2 cycles concurrent with radiation therapy. CISplatin
50mg/m2 IV on Days 1 and 8, etoposide 50 mg/m2 IV Days 1, 2, 3, 4 and 5, (Cycle 1 starts on Day 1 = first week of radiation
therapy and Cycle 2 starts on Day 29 = last week of radiation therapy); CYCLE LENGTH: 28 days; COURSE: 2 cycles
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
Treatment Medications
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ZZtestonc,Andrew [2428787]
11/28/2016 2:32:00 PM Page 4 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

etoposide (VEPESID) 90 mg in sodium chloride 0.9 % 500 mL NSS bag
90 mg (rounded from 89.5 mg = 50 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
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 4, Cycle 1 – Planned for 12/1/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer; THERAPY: CISplatin / etoposide for 2 cycles concurrent with radiation therapy. CISplatin
50mg/m2 IV on Days 1 and 8, etoposide 50 mg/m2 IV Days 1, 2, 3, 4 and 5, (Cycle 1 starts on Day 1 = first week of radiation
therapy and Cycle 2 starts on Day 29 = last week of radiation therapy); CYCLE LENGTH: 28 days; COURSE: 2 cycles
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Premedication for chemotherapy.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
etoposide (VEPESID) 90 mg in sodium chloride 0.9 % 500 mL NSS bag
90 mg (rounded from 89.5 mg = 50 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
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 1 – Planned for 12/2/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer; THERAPY: CISplatin / etoposide for 2 cycles concurrent with radiation therapy. CISplatin
50mg/m2 IV on Days 1 and 8, etoposide 50 mg/m2 IV Days 1, 2, 3, 4 and 5, (Cycle 1 starts on Day 1 = first week of radiation
therapy and Cycle 2 starts on Day 29 = last week of radiation therapy); CYCLE LENGTH: 28 days; COURSE: 2 cycles
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ZZtestonc,Andrew [2428787]
11/28/2016 2:32:00 PM Page 5 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
etoposide (VEPESID) 90 mg in sodium chloride 0.9 % 500 mL NSS bag
90 mg (rounded from 89.5 mg = 50 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
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 1 – Planned for 12/5/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer; THERAPY: CISplatin / etoposide for 2 cycles concurrent with radiation therapy. CISplatin
50mg/m2 IV on Days 1 and 8, etoposide 50 mg/m2 IV Days 1, 2, 3, 4 and 5, (Cycle 1 starts on Day 1 = first week of radiation
therapy and Cycle 2 starts on Day 29 = last week of radiation therapy); CYCLE LENGTH: 28 days; COURSE: 2 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+3 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+3 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+3 Approximate, Expires-S+365, Routine
BUN
Expected-S+3 Approximate, Expires-S+365, Routine
CREATININE
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ZZtestonc,Andrew [2428787]
11/28/2016 2:32:00 PM Page 6 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Expected-S+3 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+3 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+3 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+3 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+3 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+3 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
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
Treatment Medications
CISplatin (PLATINOL) 90 mg in sodium chloride 0.9 % 1,000 mL bag
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ZZtestonc,Andrew [2428787]
11/28/2016 2:32:00 PM Page 7 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

90 mg (rounded from 89.5 mg = 50 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
For 60-90 minutes.
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 12/26/2016 through 1/22/2017 (28 days), Planned
Day 1, Cycle 2 – Planned for 12/26/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer; THERAPY: CISplatin / etoposide for 2 cycles concurrent with radiation therapy. CISplatin
50mg/m2 IV on Days 1 and 8, etoposide 50 mg/m2 IV Days 1, 2, 3, 4 and 5, (Cycle 1 starts on Day 1 = first week of radiation
therapy and Cycle 2 starts on Day 29 = last week of radiation therapy); CYCLE LENGTH: 28 days; COURSE: 2 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 2:32:00 PM Page 8 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
Treatment Medications
CISplatin (PLATINOL) 90 mg in sodium chloride 0.9 % 1,000 mL bag
90 mg (rounded from 89.5 mg = 50 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60-90 minutes.
etoposide (VEPESID) 90 mg in sodium chloride 0.9 % 500 mL NSS bag
90 mg (rounded from 89.5 mg = 50 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
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
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ZZtestonc,Andrew [2428787]
11/28/2016 2:32:00 PM Page 9 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: etoposide 60 minutes
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: etoposide 60 minutes
DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: etoposide 60 minutes
DAY 5 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: etoposide 60 minutes
DAY 8 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: CISplatin 120 minutes.
LABS: CBC, ANC (DIFF if to be done locally), Electrolytes, BUN, Creatinine, Calcium, Alkaline Phosphatase, AST, Albumin and
Total Bilirubin.
DAY 29 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 for 210 minutes.
Day 2, Cycle 2 – Planned for 12/27/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer; THERAPY: CISplatin / etoposide for 2 cycles concurrent with radiation therapy. CISplatin
50mg/m2 IV on Days 1 and 8, etoposide 50 mg/m2 IV Days 1, 2, 3, 4 and 5, (Cycle 1 starts on Day 1 = first week of radiation
therapy and Cycle 2 starts on Day 29 = last week of radiation therapy); CYCLE LENGTH: 28 days; COURSE: 2 cycles
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
Treatment Medications
etoposide (VEPESID) 90 mg in sodium chloride 0.9 % 500 mL NSS bag
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ZZtestonc,Andrew [2428787]
11/28/2016 2:32:00 PM Page 10 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

90 mg (rounded from 89.5 mg = 50 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
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 2 – Planned for 12/28/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer; THERAPY: CISplatin / etoposide for 2 cycles concurrent with radiation therapy. CISplatin
50mg/m2 IV on Days 1 and 8, etoposide 50 mg/m2 IV Days 1, 2, 3, 4 and 5, (Cycle 1 starts on Day 1 = first week of radiation
therapy and Cycle 2 starts on Day 29 = last week of radiation therapy); CYCLE LENGTH: 28 days; COURSE: 2 cycles
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
Treatment Medications
etoposide (VEPESID) 90 mg in sodium chloride 0.9 % 500 mL NSS bag
90 mg (rounded from 89.5 mg = 50 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
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 4, Cycle 2 – Planned for 12/29/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer; THERAPY: CISplatin / etoposide for 2 cycles concurrent with radiation therapy. CISplatin
50mg/m2 IV on Days 1 and 8, etoposide 50 mg/m2 IV Days 1, 2, 3, 4 and 5, (Cycle 1 starts on Day 1 = first week of radiation
therapy and Cycle 2 starts on Day 29 = last week of radiation therapy); CYCLE LENGTH: 28 days; COURSE: 2 cycles
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ZZtestonc,Andrew [2428787]
11/28/2016 2:32:00 PM Page 11 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Premedication for chemotherapy.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
etoposide (VEPESID) 90 mg in sodium chloride 0.9 % 500 mL NSS bag
90 mg (rounded from 89.5 mg = 50 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
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 2 – Planned for 12/30/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer; THERAPY: CISplatin / etoposide for 2 cycles concurrent with radiation therapy. CISplatin
50mg/m2 IV on Days 1 and 8, etoposide 50 mg/m2 IV Days 1, 2, 3, 4 and 5, (Cycle 1 starts on Day 1 = first week of radiation
therapy and Cycle 2 starts on Day 29 = last week of radiation therapy); CYCLE LENGTH: 28 days; COURSE: 2 cycles
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
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ZZtestonc,Andrew [2428787]
11/28/2016 2:32:00 PM Page 12 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
etoposide (VEPESID) 90 mg in sodium chloride 0.9 % 500 mL NSS bag
90 mg (rounded from 89.5 mg = 50 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
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 2 – Planned for 1/2/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer; THERAPY: CISplatin / etoposide for 2 cycles concurrent with radiation therapy. CISplatin
50mg/m2 iv on Days 1 and 8, etoposide 50 mg/m2 IV Days 1, 2, 3, 4 and 5, (Cycle 1 starts on Day 1 = first week of radiation therapy
and Cycle 2 starts on Day 29 = last week of radiation therapy); CYCLE LENGTH: 28 days; COURSE: 2 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+3 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+3 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+3 Approximate, Expires-S+365, Routine
BUN
Expected-S+3 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+3 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+3 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+3 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+3 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+3 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+3 Approximate, Expires-S+365, Routine
Treatment Conditions
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ZZtestonc,Andrew [2428787]
11/28/2016 2:32:00 PM Page 13 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
Treatment Medications
CISplatin (PLATINOL) 90 mg in sodium chloride 0.9 % 1,000 mL bag
90 mg (rounded from 89.5 mg = 50 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60-90 minutes.
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
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 2:32:00 PM Page 14 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org