/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-96978-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 Dacarbazine(21D:1) VER 10-3-16 (HL 946)

CSC Melanoma Dacarbazine(21D:1) VER 10-3-16 (HL 946) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Melanoma


CSC MELANOMA DACARBAZINE(21D:1) OR (28D: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: dacarbazine 1000 mg/m2 IV Day 1; CYCLE LENGTH: 21 to 28 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, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S Approximate, Expires-S+397, Routine
ALT/SGPT
Expected-S Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S Approximate, Expires-S+397, Routine
LD, TOTAL
Expected-S Approximate, Expires-S+365, Routine
Take Home Medications
aprepitant (EMEND) 80 MG cap
Take 1 cap by mouth one time daily. Take for 2 days following chemotherapy., 80 mg, Disp-2 cap, R-5, 1 X DAILY starting S
dexamethasone (DECADRON) 4 MG tab
Take 2 tabs by mouth one time daily. Take for 3 days following chemotherapy, 8 mg, Disp-24 tab, R-5, 1 X DAILY starting S, Local
Printer
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: Bajetta E et al, Semin Oncol 2002:29(5):427-45.
Reference Information (2)
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ZZtestonc,Andrew [2428787]
11/28/2016 3:34:34 PM Page 1 of 13
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

MELANOMA: Chapman PB et al, J Clin Oncol 1999:17(9):2745-51.
Treatment Plan Summary
DISEASE: Melanoma (Advanced); THERAPY: dacarbazine 1000 mg/m2 IV Day 1; CYCLE LENGTH: 21 to 28 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.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, AST, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL, Platelets less than or equal to 100K/µL, Creatinine
greater than or equal to 1.6 mg/dL, AST greater than 2 X ULN, Total Bilirubin greater than 2 X ULN.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
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
dacarbazine (DTIC-DOME) 1,790 mg in sodium chloride 0.9 % 250 mL bag
1,790 mg (1,000 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Additional Sodium Chloride 0.9% IV may be y-set into IV site to decrease site irritation. Protect from light.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally).
DAY 22 FOLLOW-UP
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ZZtestonc,Andrew [2428787]
11/28/2016 3:34:34 PM Page 2 of 13
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, ANC (DIFF if to be done
locally), Creatinine, Alkaline Phosphatase, AST, ALT, LDH, and Total Bilirubin; CHEMOTHERAPY ROOM
APPOINTMENT: dacarbazine for 90 minutes.
Day 10 Lab Only, Cycle 1 – Planned for 12/7/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Advanced); THERAPY: dacarbazine 1000 mg/m2 IV Day 1; CYCLE LENGTH: 21 to 28 days; COURSE: until
disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 12/19/2016 through 1/8/2017 (21 days), Planned
Day 1, Cycle 2 – Planned for 12/19/2016
Treatment Plan Information
Reference Information (1)
MELANOMA: Bajetta E et al, Semin Oncol 2002:29(5):427-45.
Reference Information (2)
MELANOMA: Chapman PB et al, J Clin Oncol 1999:17(9):2745-51.
Treatment Plan Summary
DISEASE: Melanoma (Advanced); THERAPY: dacarbazine 1000 mg/m2 IV Day 1; CYCLE LENGTH: 21 to 28 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, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
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ZZtestonc,Andrew [2428787]
11/28/2016 3:34:34 PM Page 3 of 13
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
LD, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, AST, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL, Platelets less than or equal to 100K/µL, Creatinine
greater than or equal to 1.6 mg/dL, AST greater than 2 X ULN, Total Bilirubin greater than 2 X ULN.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
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
dacarbazine (DTIC-DOME) 1,790 mg in sodium chloride 0.9 % 250 mL bag
1,790 mg (1,000 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Additional Sodium Chloride 0.9% IV may be y-set into IV site to decrease site irritation. Protect from light.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine,
Alkaline Phosphatase, AST, ALT, LDH, and Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: dacarbazine for 90 minutes.
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ZZtestonc,Andrew [2428787]
11/28/2016 3:34:34 PM Page 4 of 13
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Day 10 Lab Only, Cycle 2 – Planned for 12/28/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Advanced); THERAPY: dacarbazine 1000 mg/m2 IV Day 1; CYCLE LENGTH: 21 to 28 days; COURSE: until
disease progression.
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)
MELANOMA: Bajetta E et al, Semin Oncol 2002:29(5):427-45.
Reference Information (2)
MELANOMA: Chapman PB et al, J Clin Oncol 1999:17(9):2745-51.
Treatment Plan Summary
DISEASE: Melanoma (Advanced); THERAPY: dacarbazine 1000 mg/m2 IV Day 1; CYCLE LENGTH: 21 to 28 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, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
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ZZtestonc,Andrew [2428787]
11/28/2016 3:34:34 PM Page 5 of 13
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
LD, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, AST, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL, Platelets less than or equal to 100K/µL, Creatinine
greater than or equal to 1.6 mg/dL, AST greater than 2 X ULN, Total Bilirubin greater than 2 X ULN.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
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
dacarbazine (DTIC-DOME) 1,790 mg in sodium chloride 0.9 % 250 mL bag
1,790 mg (1,000 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Additional Sodium Chloride 0.9% IV may be y-set into IV site to decrease site irritation. Protect from light.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine,
Alkaline Phosphatase, AST, ALT, LDH, and Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: dacarbazine for 90 minutes.
Day 10 Lab Only, Cycle 3 – Planned for 1/18/2017
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ZZtestonc,Andrew [2428787]
11/28/2016 3:34:34 PM Page 6 of 13
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: dacarbazine 1000 mg/m2 IV Day 1; CYCLE LENGTH: 21 to 28 days; COURSE: until
disease progression.
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)
MELANOMA: Bajetta E et al, Semin Oncol 2002:29(5):427-45.
Reference Information (2)
MELANOMA: Chapman PB et al, J Clin Oncol 1999:17(9):2745-51.
Treatment Plan Summary
DISEASE: Melanoma (Advanced); THERAPY: dacarbazine 1000 mg/m2 IV Day 1; CYCLE LENGTH: 21 to 28 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, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
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ZZtestonc,Andrew [2428787]
11/28/2016 3:34:34 PM Page 7 of 13
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
LD, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, AST, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL, Platelets less than or equal to 100K/µL, Creatinine
greater than or equal to 1.6 mg/dL, AST greater than 2 X ULN, Total Bilirubin greater than 2 X ULN.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
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
dacarbazine (DTIC-DOME) 1,790 mg in sodium chloride 0.9 % 250 mL bag
1,790 mg (1,000 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Additional Sodium Chloride 0.9% IV may be y-set into IV site to decrease site irritation. Protect from light.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine,
Alkaline Phosphatase, AST, ALT, LDH, and Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: dacarbazine for 90 minutes.
Day 10 Lab Only, Cycle 4 – Planned for 2/8/2017
Treatment Plan Information
Treatment Plan Summary
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ZZtestonc,Andrew [2428787]
11/28/2016 3:34:34 PM Page 8 of 13
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DISEASE: Melanoma (Advanced); THERAPY: dacarbazine 1000 mg/m2 IV Day 1; CYCLE LENGTH: 21 to 28
days; COURSE: until disease progression.
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 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)
MELANOMA: Bajetta E et al, Semin Oncol 2002:29(5):427-45.
Reference Information (2)
MELANOMA: Chapman PB et al, J Clin Oncol 1999:17(9):2745-51.
Treatment Plan Summary
DISEASE: Melanoma (Advanced); THERAPY: dacarbazine 1000 mg/m2 IV Day 1; CYCLE LENGTH: 21 to 28 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, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+21 Approximate, Expires-S+365, Routine
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ZZtestonc,Andrew [2428787]
11/28/2016 3:34:34 PM Page 9 of 13
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
LD, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, AST, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL, Platelets less than or equal to 100K/µL, Creatinine
greater than or equal to 1.6 mg/dL, AST greater than 2 X ULN, Total Bilirubin greater than 2 X ULN.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
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
dacarbazine (DTIC-DOME) 1,790 mg in sodium chloride 0.9 % 250 mL bag
1,790 mg (1,000 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Additional Sodium Chloride 0.9% IV may be y-set into IV site to decrease site irritation. Protect from light.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine,
Alkaline Phosphatase, AST, ALT, LDH, and Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: dacarbazine for 90 minutes.
Day 10 Lab Only, Cycle 5 – Planned for 3/1/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Advanced); THERAPY: dacarbazine 1000 mg/m2 IV Day 1; CYCLE LENGTH: 21 to 28 days; COURSE: until
disease progression.
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ZZtestonc,Andrew [2428787]
11/28/2016 3:34:34 PM Page 10 of 13
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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)
MELANOMA: Bajetta E et al, Semin Oncol 2002:29(5):427-45.
Reference Information (2)
MELANOMA: Chapman PB et al, J Clin Oncol 1999:17(9):2745-51.
Treatment Plan Summary
DISEASE: Melanoma (Advanced); THERAPY: dacarbazine 1000 mg/m2 IV Day 1; CYCLE LENGTH: 21 to 28 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, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+21 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+21 Approximate, Expires-S+365, Routine
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ZZtestonc,Andrew [2428787]
11/28/2016 3:34:34 PM Page 11 of 13
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

LD, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, AST, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL, Platelets less than or equal to 100K/µL, Creatinine
greater than or equal to 1.6 mg/dL, AST greater than 2 X ULN, Total Bilirubin greater than 2 X ULN.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
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
dacarbazine (DTIC-DOME) 1,790 mg in sodium chloride 0.9 % 250 mL bag
1,790 mg (1,000 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Additional Sodium Chloride 0.9% IV may be y-set into IV site to decrease site irritation. Protect from light.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine,
Alkaline Phosphatase, AST, ALT, LDH, and Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: dacarbazine for 90 minutes.
Day 10 Lab Only, Cycle 6 – Planned for 3/22/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Advanced); THERAPY: dacarbazine 1000 mg/m2 IV Day 1; CYCLE LENGTH: 21 to 28 days; COURSE: until
disease progression.
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/28/2016 3:34:34 PM Page 12 of 13
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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ZZtestonc,Andrew [2428787]
11/28/2016 3:34:34 PM Page 13 of 13
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org