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/clinical/cckm-tools/content/beacon-protocols/lung/name-96965-en.cckm

201611333

page

100

UWHC,UWMF,

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

CSC Lung Cisplatin(21D:1) Cyclophosphamide(21D:1) Doxorubicin(21D:1) VER 10-3-16 (HL 4345)

CSC Lung Cisplatin(21D:1) Cyclophosphamide(21D:1) Doxorubicin(21D:1) VER 10-3-16 (HL 4345) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Lung


CSC LUNG CISPLATIN(21D:1)/CYCLOPHOSPHAMIDE(21D:1)/DOXORUBICIN(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: Thymic Malignancies (Adjuvant/Advanced), Salivary Gland Cancer (Advanced); THERAPY: doxorubicin 50 mg/m2 IV
Day 1, CISplatin 50 mg/m2 IV Day 1, cyclophosphamide 500 mg/m2 IV Day 1; CYCLE LENGTH: 21 days; COURSE: maximum of 8
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
GLUCOSE
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
PROTEIN, TOTAL
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
ALT/SGPT
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-7, 1 X DAILY starting S, Local
Printer
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-1, 1 X DAILY starting S, Local
Printer
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ZZtestonc,Andrew [2428787]
11/28/2016 2:16:53 PM Page 1 of 22
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
Day 1, Cycle 1 – Planned for 11/28/2016
Treatment Plan Information
Reference Information (1)
THYMIC MALIGNANCIES: Loehrer PJ, et al. J Clin Onc 1994;12:1164-8
Reference Information (2)
SALIVARY GLAND (Advanced): Laurie SA, et al. Clin Oncol. 2006;24(17):2673-8.
Treatment Plan Summary
DISEASE: Thymic Malignancies (Adjuvant/Advanced), Salivary Gland Cancer (Advanced); THERAPY: doxorubicin 50 mg/m2 IV
Day 1, CISplatin 50 mg/m2 IV Day 1, cyclophosphamide 500 mg/m2 IV Day 1; CYCLE LENGTH: 21 days; COURSE: maximum of 8
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: WBC, ANC, Platelets, Sodium, Potassium, Chloride, Carbon Dioxide, Glucose, BUN,
Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Magnesium.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL or Creatinine greater than ULN or
Total Bilirubin greater than or equal to 1.8 mg/dL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
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
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ZZtestonc,Andrew [2428787]
11/28/2016 2:16:53 PM Page 2 of 22
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 90 mg
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
IV side arm push 3-5 mL/minute into running IV.
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
Administer over 60-90 minutes.
cyclophosphamide (CYTOXAN) 895 mg in sodium chloride 0.9 % 250 mL bag
895 mg (500 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30-60 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 to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase,
Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: Doxorubicin, CISplatin, cyclophospamide for 180 minutes.
Lab Only - Day 10 , Cycle 1 – Planned for 12/7/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Thymic Malignancies (Adjuvant/Advanced), Salivary Gland Cancer (Advanced); THERAPY: doxorubicin 50 mg/m2 IV
Day 1, CISplatin 50 mg/m2 IV Day 1, cyclophosphamide 500 mg/m2 IV Day 1; CYCLE LENGTH: 21 days; COURSE: maximum of 8
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
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ZZtestonc,Andrew [2428787]
11/28/2016 2:16:53 PM Page 3 of 22
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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)
THYMIC MALIGNANCIES: Loehrer PJ, et al. J Clin Onc 1994;12:1164-8
Reference Information (2)
SALIVARY GLAND (Advanced): Laurie SA, et al. Clin Oncol. 2006;24(17):2673-8.
Treatment Plan Summary
DISEASE: Thymic Malignancies (Adjuvant/Advanced), Salivary Gland Cancer (Advanced); THERAPY: doxorubicin 50 mg/m2 IV
Day 1, CISplatin 50 mg/m2 IV Day 1, cyclophosphamide 500 mg/m2 IV Day 1; CYCLE LENGTH: 21 days; COURSE: maximum of 8
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
GLUCOSE
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
PROTEIN, TOTAL
Expected-S+21, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
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ZZtestonc,Andrew [2428787]
11/28/2016 2:16:53 PM Page 4 of 22
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

ALT/SGPT
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: WBC, ANC, Platelets, Sodium, Potassium, Chloride, Carbon Dioxide, Glucose, BUN,
Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Magnesium.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL or Creatinine greater than ULN or
Total Bilirubin greater than or equal to 1.8 mg/dL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
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
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 90 mg
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
IV side arm push 3-5 mL/minute into running IV.
CISplatin (PLATINOL) 90 mg in sodium chloride 0.9 % 1,000 mL bag
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ZZtestonc,Andrew [2428787]
11/28/2016 2:16:53 PM Page 5 of 22
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 60-90 minutes.
cyclophosphamide (CYTOXAN) 895 mg in sodium chloride 0.9 % 250 mL bag
895 mg (500 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30-60 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 to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase,
Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: Doxorubicin, CISplatin, cyclophospamide for 180 minutes.
Lab Only - Day 10, Cycle 2 – Planned for 12/28/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Thymic Malignancies (Adjuvant/Advanced), Salivary Gland Cancer (Advanced); THERAPY: doxorubicin 50 mg/m2 IV
Day 1, CISplatin 50 mg/m2 IV Day 1, cyclophosphamide 500 mg/m2 IV Day 1; CYCLE LENGTH: 21 days; COURSE: maximum of 8
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 3 – 1/9/2017 through 1/29/2017 (21 days), Planned
Day 1, Cycle 3 – Planned for 1/9/2017
Treatment Plan Information
Reference Information (1)
THYMIC MALIGNANCIES: Loehrer PJ, et al. J Clin Onc 1994;12:1164-8
Reference Information (2)
SALIVARY GLAND (Advanced): Laurie SA, et al. Clin Oncol. 2006;24(17):2673-8.
Treatment Plan Summary
DISEASE: Thymic Malignancies (Adjuvant/Advanced), Salivary Gland Cancer (Advanced); THERAPY: doxorubicin 50 mg/m2 IV
Day 1, CISplatin 50 mg/m2 IV Day 1, cyclophosphamide 500 mg/m2 IV Day 1; CYCLE LENGTH: 21 days; COURSE: maximum of 8
cycles.
Consent
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ZZtestonc,Andrew [2428787]
11/28/2016 2:16:53 PM Page 6 of 22
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
GLUCOSE
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
PROTEIN, TOTAL
Expected-S+21, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
ALT/SGPT
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: WBC, ANC, Platelets, Sodium, Potassium, Chloride, Carbon Dioxide, Glucose, BUN,
Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Magnesium.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL or Creatinine greater than ULN or
Total Bilirubin greater than or equal to 1.8 mg/dL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
Measure Intake And Output
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ZZtestonc,Andrew [2428787]
11/28/2016 2:16:53 PM Page 7 of 22
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 90 mg
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
IV side arm push 3-5 mL/minute into running IV.
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
Administer over 60-90 minutes.
cyclophosphamide (CYTOXAN) 895 mg in sodium chloride 0.9 % 250 mL bag
895 mg (500 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30-60 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 to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase,
Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: Doxorubicin, CISplatin, cyclophospamide for 180 minutes.
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ZZtestonc,Andrew [2428787]
11/28/2016 2:16:53 PM Page 8 of 22
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 3 – Planned for 1/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Thymic Malignancies (Adjuvant/Advanced), Salivary Gland Cancer (Advanced); THERAPY: doxorubicin 50 mg/m2 IV
Day 1, CISplatin 50 mg/m2 IV Day 1, cyclophosphamide 500 mg/m2 IV Day 1; CYCLE LENGTH: 21 days; COURSE: maximum of 8
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
Reference Information (1)
THYMIC MALIGNANCIES: Loehrer PJ, et al. J Clin Onc 1994;12:1164-8
Reference Information (2)
SALIVARY GLAND (Advanced): Laurie SA, et al. Clin Oncol. 2006;24(17):2673-8.
Treatment Plan Summary
DISEASE: Thymic Malignancies (Adjuvant/Advanced), Salivary Gland Cancer (Advanced); THERAPY: doxorubicin 50 mg/m2 IV
Day 1, CISplatin 50 mg/m2 IV Day 1, cyclophosphamide 500 mg/m2 IV Day 1; CYCLE LENGTH: 21 days; COURSE: maximum of 8
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
GLUCOSE
Expected-S+21 Approximate, Expires-S+365, Routine
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ZZtestonc,Andrew [2428787]
11/28/2016 2:16:53 PM Page 9 of 22
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

BUN
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+21 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+21 Approximate, Expires-S+365, Routine
PROTEIN, TOTAL
Expected-S+21, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
ALT/SGPT
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: WBC, ANC, Platelets, Sodium, Potassium, Chloride, Carbon Dioxide, Glucose, BUN,
Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Magnesium.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL or Creatinine greater than ULN or
Total Bilirubin greater than or equal to 1.8 mg/dL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
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
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ZZtestonc,Andrew [2428787]
11/28/2016 2:16:53 PM Page 10 of 22
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 90 mg
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
IV side arm push 3-5 mL/minute into running IV.
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
Administer over 60-90 minutes.
cyclophosphamide (CYTOXAN) 895 mg in sodium chloride 0.9 % 250 mL bag
895 mg (500 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30-60 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 to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase,
Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: Doxorubicin, CISplatin, cyclophospamide for 180 minutes.
Lab Only - Day 10, Cycle 4 – Planned for 2/8/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Thymic Malignancies (Adjuvant/Advanced), Salivary Gland Cancer (Advanced); THERAPY: doxorubicin 50 mg/m2 IV
Day 1, CISplatin 50 mg/m2 IV Day 1, cyclophosphamide 500 mg/m2 IV Day 1; CYCLE LENGTH: 21 days; COURSE: maximum of 8
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
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ZZtestonc,Andrew [2428787]
11/28/2016 2:16:53 PM Page 11 of 22
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 – 2/20/2017 through 3/12/2017 (21 days), Planned
Day 1, Cycle 5 – Planned for 2/20/2017
Treatment Plan Information
Reference Information (1)
THYMIC MALIGNANCIES: Loehrer PJ, et al. J Clin Onc 1994;12:1164-8
Reference Information (2)
SALIVARY GLAND (Advanced): Laurie SA, et al. Clin Oncol. 2006;24(17):2673-8.
Treatment Plan Summary
DISEASE: Thymic Malignancies (Adjuvant/Advanced), Salivary Gland Cancer (Advanced); THERAPY: doxorubicin 50 mg/m2 IV
Day 1, CISplatin 50 mg/m2 IV Day 1, cyclophosphamide 500 mg/m2 IV Day 1; CYCLE LENGTH: 21 days; COURSE: maximum of 8
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
GLUCOSE
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
PROTEIN, TOTAL
Expected-S+21, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+21 Approximate, Expires-S+365, Routine
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ZZtestonc,Andrew [2428787]
11/28/2016 2:16:53 PM Page 12 of 22
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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: WBC, ANC, Platelets, Sodium, Potassium, Chloride, Carbon Dioxide, Glucose, BUN,
Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Magnesium.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL or Creatinine greater than ULN or
Total Bilirubin greater than or equal to 1.8 mg/dL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
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
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 90 mg
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
IV side arm push 3-5 mL/minute into running IV.
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
Administer over 60-90 minutes.
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ZZtestonc,Andrew [2428787]
11/28/2016 2:16:53 PM Page 13 of 22
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

cyclophosphamide (CYTOXAN) 895 mg in sodium chloride 0.9 % 250 mL bag
895 mg (500 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Administer over 30-60 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 to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase,
Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: Doxorubicin, CISplatin, cyclophospamide for 180 minutes.
Lab Only - Day 10, Cycle 5 – Planned for 3/1/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Thymic Malignancies (Adjuvant/Advanced), Salivary Gland Cancer (Advanced); THERAPY: doxorubicin 50 mg/m2 IV
Day 1, CISplatin 50 mg/m2 IV Day 1, cyclophosphamide 500 mg/m2 IV Day 1; CYCLE LENGTH: 21 days; COURSE: maximum of 8
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 6 – 3/13/2017 through 4/2/2017 (21 days), Planned
Day 1, Cycle 6 – Planned for 3/13/2017
Treatment Plan Information
Reference Information (1)
THYMIC MALIGNANCIES: Loehrer PJ, et al. J Clin Onc 1994;12:1164-8
Reference Information (2)
SALIVARY GLAND (Advanced): Laurie SA, et al. Clin Oncol. 2006;24(17):2673-8.
Treatment Plan Summary
DISEASE: Thymic Malignancies (Adjuvant/Advanced), Salivary Gland Cancer (Advanced); THERAPY: doxorubicin 50 mg/m2 IV
Day 1, CISplatin 50 mg/m2 IV Day 1, cyclophosphamide 500 mg/m2 IV Day 1; CYCLE LENGTH: 21 days; COURSE: maximum of 8
cycles.
Consent
Verify Consent
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ZZtestonc,Andrew [2428787]
11/28/2016 2:16:53 PM Page 14 of 22
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
GLUCOSE
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
PROTEIN, TOTAL
Expected-S+21, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
ALT/SGPT
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: WBC, ANC, Platelets, Sodium, Potassium, Chloride, Carbon Dioxide, Glucose, BUN,
Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Magnesium.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL or Creatinine greater than ULN or
Total Bilirubin greater than or equal to 1.8 mg/dL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
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.
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ZZtestonc,Andrew [2428787]
11/28/2016 2:16:53 PM Page 15 of 22
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 90 mg
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
IV side arm push 3-5 mL/minute into running IV.
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
Administer over 60-90 minutes.
cyclophosphamide (CYTOXAN) 895 mg in sodium chloride 0.9 % 250 mL bag
895 mg (500 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30-60 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 to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase,
Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: Doxorubicin, CISplatin, cyclophospamide for 180 minutes.
Lab Only - Day 10, Cycle 6 – Planned for 3/22/2017
Treatment Plan Information
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ZZtestonc,Andrew [2428787]
11/28/2016 2:16:53 PM Page 16 of 22
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Thymic Malignancies (Adjuvant/Advanced), Salivary Gland Cancer (Advanced); THERAPY: doxorubicin
50 mg/m2 IV Day 1, CISplatin 50 mg/m2 IV Day 1, cyclophosphamide 500 mg/m2 IV Day 1; CYCLE LENGTH: 21
days; COURSE: maximum of 8 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 7 – 4/3/2017 through 4/23/2017 (21 days), Planned
Day 1, Cycle 7 – Planned for 4/3/2017
Treatment Plan Information
Reference Information (1)
THYMIC MALIGNANCIES: Loehrer PJ, et al. J Clin Onc 1994;12:1164-8
Reference Information (2)
SALIVARY GLAND (Advanced): Laurie SA, et al. Clin Oncol. 2006;24(17):2673-8.
Treatment Plan Summary
DISEASE: Thymic Malignancies (Adjuvant/Advanced), Salivary Gland Cancer (Advanced); THERAPY: doxorubicin 50 mg/m2 IV
Day 1, CISplatin 50 mg/m2 IV Day 1, cyclophosphamide 500 mg/m2 IV Day 1; CYCLE LENGTH: 21 days; COURSE: maximum of 8
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
GLUCOSE
Expected-S+21 Approximate, Expires-S+365, Routine
BUN
Expected-S+21 Approximate, Expires-S+365, Routine
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ZZtestonc,Andrew [2428787]
11/28/2016 2:16:53 PM Page 17 of 22
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
PROTEIN, TOTAL
Expected-S+21, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
ALT/SGPT
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: WBC, ANC, Platelets, Sodium, Potassium, Chloride, Carbon Dioxide, Glucose, BUN,
Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Magnesium.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL or Creatinine greater than ULN or
Total Bilirubin greater than or equal to 1.8 mg/dL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
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
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ZZtestonc,Andrew [2428787]
11/28/2016 2:16:53 PM Page 18 of 22
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 90 mg
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
IV side arm push 3-5 mL/minute into running IV.
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
Administer over 60-90 minutes.
cyclophosphamide (CYTOXAN) 895 mg in sodium chloride 0.9 % 250 mL bag
895 mg (500 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30-60 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 to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase,
Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: Doxorubicin, CISplatin, cyclophospamide for 180 minutes.
Lab Only - Day 10, Cycle 7 – Planned for 4/12/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Thymic Malignancies (Adjuvant/Advanced), Salivary Gland Cancer (Advanced); THERAPY: doxorubicin 50 mg/m2 IV
Day 1, CISplatin 50 mg/m2 IV Day 1, cyclophosphamide 500 mg/m2 IV Day 1; CYCLE LENGTH: 21 days; COURSE: maximum of 8
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 2:16:53 PM Page 19 of 22
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Cycle 8 – 4/24/2017 through 5/14/2017 (21 days), Planned
Day 1, Cycle 8 – Planned for 4/24/2017
Treatment Plan Information
Reference Information (1)
THYMIC MALIGNANCIES: Loehrer PJ, et al. J Clin Onc 1994;12:1164-8
Reference Information (2)
SALIVARY GLAND (Advanced): Laurie SA, et al. Clin Oncol. 2006;24(17):2673-8.
Treatment Plan Summary
DISEASE: Thymic Malignancies (Adjuvant/Advanced), Salivary Gland Cancer (Advanced); THERAPY: doxorubicin 50 mg/m2 IV
Day 1, CISplatin 50 mg/m2 IV Day 1, cyclophosphamide 500 mg/m2 IV Day 1; CYCLE LENGTH: 21 days; COURSE: maximum of 8
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
GLUCOSE
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
PROTEIN, TOTAL
Expected-S+21, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+21 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+21 Approximate, Expires-S+365, Routine
MAGNESIUM
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ZZtestonc,Andrew [2428787]
11/28/2016 2:16:53 PM Page 20 of 22
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
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: WBC, ANC, Platelets, Sodium, Potassium, Chloride, Carbon Dioxide, Glucose, BUN,
Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Magnesium.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL or Creatinine greater than ULN or
Total Bilirubin greater than or equal to 1.8 mg/dL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
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
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 90 mg
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
IV side arm push 3-5 mL/minute into running IV.
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
Administer over 60-90 minutes.
cyclophosphamide (CYTOXAN) 895 mg in sodium chloride 0.9 % 250 mL bag
895 mg (500 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30-60 minutes.
Conditional Orders
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ZZtestonc,Andrew [2428787]
11/28/2016 2:16:53 PM Page 21 of 22
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 to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase,
Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: Doxorubicin, CISplatin, cyclophospamide for 180 minutes.
Lab Only - Day 10, Cycle 8 – Planned for 5/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Thymic Malignancies (Adjuvant/Advanced), Salivary Gland Cancer (Advanced); THERAPY: doxorubicin 50 mg/m2 IV
Day 1, CISplatin 50 mg/m2 IV Day 1, cyclophosphamide 500 mg/m2 IV Day 1; CYCLE LENGTH: 21 days; COURSE: maximum of 8
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 2:16:53 PM Page 22 of 22
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org