/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/beacon-protocols/,/clinical/cckm-tools/content/beacon-protocols/melanoma/,

/clinical/cckm-tools/content/beacon-protocols/melanoma/name-96975-en.cckm

201611333

page

100

UWHC,UWMF,

Tools,

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

CSC Melanoma Carboplatin(21D:1) Paclitaxel(21D:1) VER 10-3-16 (HL 3270)

CSC Melanoma Carboplatin(21D:1) Paclitaxel(21D:1) VER 10-3-16 (HL 3270) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Melanoma


CSC MELANOMA CARBOPLATIN(21D:1)/PACLITAXEL(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: Melanoma (Advanced); THERAPY: PACLItaxel 225 mg/m2 IV Day 1, CARBOplatin AUC=6 IV Day 1; CYCLE LENGTH:
21 days; COURSE: until disease progression
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S Approximate, Expires-S+365, Normal, Routine
ELECTROLYTES
Expected-S Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S Approximate, Expires-S+365, Routine
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
Take 5 tabs by mouth 12 & 6 hours prior to PACLItaxel and 2 tabs once daily on Days 2, 3, and 4., Disp-50 tab, R-1, starting S
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., 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)
MELANOMA: Hauschild A, et al. J Clin Oncol. 2009;27(17):2823-30.
Treatment Plan Summary
DISEASE: Melanoma (Advanced); THERAPY: PACLItaxel 225 mg/m2 IV Day 1, CARBOplatin AUC=6 IV Day 1; CYCLE LENGTH:
21 days; COURSE: until disease progression
Consent
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ZZtestonc,Andrew [2428787]
11/28/2016 3:31:11 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

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: ANC, Platelets, Creatinine, Total Bilirubin, AST, ALT.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL or Total Bilirubin greater
than or equal to 1.5 mg/dL or AST greater than or equal to 2.5 X ULN or ALT greater than or equal to 2.5 X ULN.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care.
** Rush dextrose primed line with 18mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone).
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes.
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care.
Vital Signs
SEE COMMENTS Starting when released for 1 day
PACLItaxel: Monitor vital signs every 15 minutes for the first hour then every 30 minutes for the remainder of the infusion for the first
and second dose. If previous doses tolerated, monitor vital signs every 30 minutes for all subsequent doses.
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) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN Starting when released Until Discontinued, If PO not taken at home.
For use in patients who did not take dexamethasone at home.
diphenhydramine (BENADRYL) injection 50 mg
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ZZtestonc,Andrew [2428787]
11/28/2016 3:31:11 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

50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Give 30 minutes prior to PACLItaxel.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Give 30 minutes prior to PACLItaxel.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 403 mg in dextrose 5 % 500 mL non-PVC bag
403 mg (rounded from 402.75 mg = 225 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Hypersensitivity risk. See emergency medications. Infuse over 180 minutes. Use non-PVC tubing and 0.22 micron in-line filter during
administration.
CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
(Target AUC = 6), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC (CBC with DIFF if drawn
locally), Creatinine, Total Bilirubin, AST, ALT, Electrolytes, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel and
CARBOplatin for 300 minutes
Cycle 2 – 12/19/2016 through 1/8/2017 (21 days), Planned
Day 1, Cycle 2 – Planned for 12/19/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Advanced); THERAPY: PACLItaxel 225 mg/m2 IV Day 1, CARBOplatin AUC=6 IV Day 1; CYCLE LENGTH:
21 days; COURSE: until disease progression
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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ZZtestonc,Andrew [2428787]
11/28/2016 3:31:11 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

CBC WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
ELECTROLYTES
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: ANC, Platelets, Creatinine, Total Bilirubin, AST, ALT.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL or Total Bilirubin greater
than or equal to 1.5 mg/dL or AST greater than or equal to 2.5 X ULN or ALT greater than or equal to 2.5 X ULN.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care.
** Rush dextrose primed line with 18mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone).
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes.
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care.
Vital Signs
SEE COMMENTS Starting when released for 1 day
PACLItaxel: Monitor vital signs every 15 minutes for the first hour then every 30 minutes for the remainder of the infusion for the first
and second dose. If previous doses tolerated, monitor vital signs every 30 minutes for all subsequent doses.
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 3:31:11 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

sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Pre-Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Give 30 minutes prior to PACLItaxel.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Give 30 minutes prior to PACLItaxel.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 403 mg in dextrose 5 % 500 mL non-PVC bag
403 mg (rounded from 402.75 mg = 225 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Hypersensitivity risk. See emergency medications. Infuse over 180 minutes. Use non-PVC tubing and 0.22 micron in-line filter during
administration.
CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
(Target AUC = 6), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC (CBC with DIFF if drawn
locally), Creatinine, Total Bilirubin, AST, ALT, Electrolytes, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel and
CARBOplatin for 300 minutes
Cycle 3 – 1/9/2017 through 1/29/2017 (21 days), Planned
Day 1, Cycle 3 – Planned for 1/9/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Advanced); THERAPY: PACLItaxel 225 mg/m2 IV Day 1, CARBOplatin AUC=6 IV Day 1; CYCLE LENGTH:
21 days; COURSE: until disease progression
Consent
Verify Consent
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ZZtestonc,Andrew [2428787]
11/28/2016 3:31:11 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

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, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
ELECTROLYTES
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: ANC, Platelets, Creatinine, Total Bilirubin, AST, ALT.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL or Total Bilirubin greater
than or equal to 1.5 mg/dL or AST greater than or equal to 2.5 X ULN or ALT greater than or equal to 2.5 X ULN.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care.
** Rush dextrose primed line with 18mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone).
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes.
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care.
Vital Signs
SEE COMMENTS Starting when released for 1 day
PACLItaxel: Monitor vital signs every 15 minutes for the first hour then every 30 minutes for the remainder of the infusion for the first
and second dose. If previous doses tolerated, monitor vital signs every 30 minutes for all subsequent doses.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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ZZtestonc,Andrew [2428787]
11/28/2016 3:31:11 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

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
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Give 30 minutes prior to PACLItaxel.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Give 30 minutes prior to PACLItaxel.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 403 mg in dextrose 5 % 500 mL non-PVC bag
403 mg (rounded from 402.75 mg = 225 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Hypersensitivity risk. See emergency medications. Infuse over 180 minutes. Use non-PVC tubing and 0.22 micron in-line filter during
administration.
CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
(Target AUC = 6), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC (CBC with DIFF if drawn
locally), Creatinine, Total Bilirubin, AST, ALT, Electrolytes, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel and
CARBOplatin for 300 minutes
Cycle 4 – 1/30/2017 through 2/19/2017 (21 days), Planned
Day 1, Cycle 4 – Planned for 1/30/2017
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ZZtestonc,Andrew [2428787]
11/28/2016 3:31:11 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

Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Advanced); THERAPY: PACLItaxel 225 mg/m2 IV Day 1, CARBOplatin AUC=6 IV Day 1; CYCLE LENGTH:
21 days; COURSE: until disease progression
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, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
ELECTROLYTES
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: ANC, Platelets, Creatinine, Total Bilirubin, AST, ALT.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL or Total Bilirubin greater
than or equal to 1.5 mg/dL or AST greater than or equal to 2.5 X ULN or ALT greater than or equal to 2.5 X ULN.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care.
** Rush dextrose primed line with 18mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone).
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes.
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care.
Vital Signs
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ZZtestonc,Andrew [2428787]
11/28/2016 3:31:11 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

SEE COMMENTS Starting when released for 1 day
PACLItaxel: Monitor vital signs every 15 minutes for the first hour then every 30 minutes for the remainder of the
infusion for the first and second dose. If previous doses tolerated, monitor vital signs every 30 minutes for all
subsequent doses.
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
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Give 30 minutes prior to PACLItaxel.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Give 30 minutes prior to PACLItaxel.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 403 mg in dextrose 5 % 500 mL non-PVC bag
403 mg (rounded from 402.75 mg = 225 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Hypersensitivity risk. See emergency medications. Infuse over 180 minutes. Use non-PVC tubing and 0.22 micron in-line filter during
administration.
CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
(Target AUC = 6), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications.
Follow-Up
DAY 22 FOLLOW-UP
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ZZtestonc,Andrew [2428787]
11/28/2016 3:31:11 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

(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC (CBC with
DIFF if drawn locally), Creatinine, Total Bilirubin, AST, ALT, Electrolytes, Magnesium; CHEMOTHERAPY ROOM
APPOINTMENT: PACLItaxel and CARBOplatin for 300 minutes
Cycle 5 – 2/20/2017 through 3/12/2017 (21 days), Planned
Day 1, Cycle 5 – Planned for 2/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Advanced); THERAPY: PACLItaxel 225 mg/m2 IV Day 1, CARBOplatin AUC=6 IV Day 1; CYCLE LENGTH:
21 days; COURSE: until disease progression
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, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
ELECTROLYTES
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: ANC, Platelets, Creatinine, Total Bilirubin, AST, ALT.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL or Total Bilirubin greater
than or equal to 1.5 mg/dL or AST greater than or equal to 2.5 X ULN or ALT greater than or equal to 2.5 X ULN.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care.
** Rush dextrose primed line with 18mL prior to programming start rate for infusion.
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ZZtestonc,Andrew [2428787]
11/28/2016 3:31:11 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

** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone).
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes.
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care.
Vital Signs
SEE COMMENTS Starting when released for 1 day
PACLItaxel: Monitor vital signs every 15 minutes for the first hour then every 30 minutes for the remainder of the infusion for the first
and second dose. If previous doses tolerated, monitor vital signs every 30 minutes for all subsequent doses.
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
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Give 30 minutes prior to PACLItaxel.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Give 30 minutes prior to PACLItaxel.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 403 mg in dextrose 5 % 500 mL non-PVC bag
403 mg (rounded from 402.75 mg = 225 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Hypersensitivity risk. See emergency medications. Infuse over 180 minutes. Use non-PVC tubing and 0.22 micron in-line filter during
administration.
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ZZtestonc,Andrew [2428787]
11/28/2016 3:31:11 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

CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
(Target AUC = 6), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC (CBC with DIFF if drawn
locally), Creatinine, Total Bilirubin, AST, ALT, Electrolytes, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel and
CARBOplatin for 300 minutes
Cycle 6 – 3/13/2017 through 4/2/2017 (21 days), Planned
Day 1, Cycle 6 – Planned for 3/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Advanced); THERAPY: PACLItaxel 225 mg/m2 IV Day 1, CARBOplatin AUC=6 IV Day 1; CYCLE LENGTH:
21 days; COURSE: until disease progression
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, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
ELECTROLYTES
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: ANC, Platelets, Creatinine, Total Bilirubin, AST, ALT.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL or Total Bilirubin greater
than or equal to 1.5 mg/dL or AST greater than or equal to 2.5 X ULN or ALT greater than or equal to 2.5 X ULN.
Verify Medication(s) Taken at Home (1)
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ZZtestonc,Andrew [2428787]
11/28/2016 3:31:11 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

Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care.
** Rush dextrose primed line with 18mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone).
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes.
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient should be treated in a location to optimize
emergency care.
Vital Signs
SEE COMMENTS Starting when released for 1 day
PACLItaxel: Monitor vital signs every 15 minutes for the first hour then every 30 minutes for the remainder of the infusion for the first
and second dose. If previous doses tolerated, monitor vital signs every 30 minutes for all subsequent doses.
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
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Give 30 minutes prior to PACLItaxel.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Give 30 minutes prior to PACLItaxel.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
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ZZtestonc,Andrew [2428787]
11/28/2016 3:31:11 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

Treatment Medications
PACLItaxel (TAXOL) 403 mg in dextrose 5 % 500 mL non-PVC bag
403 mg (rounded from 402.75 mg = 225 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Hypersensitivity risk. See emergency medications. Infuse over 180 minutes. Use non-PVC tubing and 0.22 micron in-line filter during
administration.
CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
(Target AUC = 6), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC (CBC with DIFF if drawn
locally), Creatinine, Total Bilirubin, AST, ALT, Electrolytes, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel and
CARBOplatin for 300 minutes
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ZZtestonc,Andrew [2428787]
11/28/2016 3:31:11 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