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CSC GU INPT TIP Cisplatin(21D:2-5) Ifosfamide(21D:2-5) Paclitaxel(21D:1) (Testicular) VER 12-1-16 (HL 1417)

CSC GU INPT TIP Cisplatin(21D:2-5) Ifosfamide(21D:2-5) Paclitaxel(21D:1) (Testicular) VER 12-1-16 (HL 1417) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GU


CSC GU INPT TIP CISPLATIN(21D2-5)IFOSFAMIDE(21D2-5)PACLITAXEL(21D1) (TESTICULAR) VER 12-1-16 (HL
1417) – Properties
Cycle 1 – 6/15/2017 through 7/5/2017 (21 days), Planned
Day 1, Cycle 1 – Planned for 6/15/2017
Treatment Plan Information
Reference Information (1)
TESTICULAR CANCER: Kondagunta G, et al. J Clin Oncol. 2005; 23(27):6549-55
Treatment Plan Summary
DISEASE: Testicular Cancer (Advanced); THERAPY: PACLItaxel 250 mg/m2 IV continuous infusion over 24 hours Day 1, CISplatin
25 mg/m2 IV Day 2 through 5, mesna 500 mg/m2 IV prior to ifosfamide and 4 hours and 8 hours after start of ifosfamide Day 2
through 5, ifosfamide 1500 mg/m2 IV Day 2 through 5; CYCLE LENGTH: 21 days; COURSE: 4 cycles; NOTE: If patient is
discharged early, order oral mesna (oral dose = 2 X IV dose) for remaining doses
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
ONCE Starting when released
ABSOLUTE NEUTROPHIL COUNT
ONCE Starting when released
ELECTROLYTES
ONCE Starting when released
BUN
ONCE Starting when released
CREATININE
ONCE Starting when released
MAGNESIUM
ONCE Starting when released
BILIRUBIN, TOTAL
ONCE Starting when released
AST/SGOT
ONCE Starting when released
ALT/SGPT
ONCE Starting when released
ALBUMIN
ONCE Starting when released
URINALYSIS WITH MICROSCOPY
NEXT AM Starting S+1 As Scheduled for 5 occurrences
AFP, TUMOR MARKER, SERUM
ONCE Starting when released
HCG, QUANTITATIVE
ONCE Starting when released, Routine
LD, TOTAL
ONCE Starting when released
Additional Labs (delete all that do not apply)
AFP, TUMOR MARKER, SERUM
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Zztestonc,Jeff J [2507481]
6/15/2017 8:06:57 AM Page 1 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Expected-S+7, Expires-S+14, Normal, Routine
DAY 8: MD to delete if not needed.
AFP, TUMOR MARKER, SERUM
Expected-S+14, Expires-S+14, Normal, Routine
DAY 15: MD to delete if not needed.
HCG, QUANTITATIVE
Expected-S+7, Expires-S+14, Normal, Routine
DAY 8: MD to delete if not needed.
HCG, QUANTITATIVE
Expected-S+14, Expires-S+14, Normal, Routine
DAY 15: MD to delete if not needed.
LD, TOTAL
Expected-S+7, Expires-S+14, Normal, Routine
DAY 8: MD to delete if not needed.
LD, TOTAL
Expected-S+14, Expires-S+14, Normal, Routine
DAY 15: MD to delete if not needed.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained on Day 1: ANC, Platelets, Creatinine, Total Bilirubin, AST, ALT, Albumin
Verify Labs (2)
Verify pretreatment labs have been obtained on Day 2 through 5: Urinalysis
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL, Platelets less than 75K/µL, Creatinine greater than 2
mg/dL or Creatinine Clearance less than 50 mL/min, Total Bilirubin greater than 2 mg/dL, AST or ALT greater than 3 X ULN or
Albumin less than 3 gm/dL.
Treatment Parameters (2)
Hold treatment and notify authorizing prescriber for Urine Hemoglobin greater than Trace prior to ifosfamide administration on Day 2
through 5.
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.
Vital Signs
SEE COMMENTS Starting when released Until Specified
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.
Monitoring Parameters (1)
Monitor for ifosfamide-related neurotoxicity (somnolence, agitation, confusion, delirium, hallucinations, incontinence, palsy, diplopia
or aphasia). Stop infusion and contact physician if toxicity is suspected.
Monitoring Parameters (2)
Monitor and notify physician for signs and symptoms of hemorrhagic cystitis (dysuria).
Measure Intake And Output
EVERY 4 HOURS Starting S+1 at 0000 Until Specified
Measure IV intake and urine output.
Flush Venous Access Device per Guidelines
Order details
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Zztestonc,Jeff J [2507481]
6/15/2017 8:06:57 AM Page 2 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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 100 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
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
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.
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous, ONCE, 1 dose Starting S+1 at 0000
Do not infuse with CA++, Mg++, Lactated Ringer's solutions
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, EVERY 24 HOURS, 4 doses Starting S+1 at 0000
Give prior to chemotherapy. May give IV if unable to tolerate PO.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, EVERY 24 HOURS PRN, 4 doses Starting S+1 at 0000, nausea/vomiting
Give prior to chemotherapy if patient unable to tolerate PO.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, EVERY 24 HOURS, 4 doses Starting S+1 at 0000
Give prior to chemotherapy. May give IV if unable to tolerate PO.
dexamethasone (DECADRON) 10 MG/ML injection 8 mg
8 mg, Intravenous, EVERY 24 HOURS PRN, For 5 days Starting S+1 at 0000, nausea/vomiting
Give prior to chemotherapy if patient unable to tolerate PO.
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
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Zztestonc,Jeff J [2507481]
6/15/2017 8:06:57 AM Page 3 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

PACLItaxel (TAXOL) 490 mg in dextrose 5 % 500 mL non-PVC bag
490 mg (250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Infuse over 24 hours. Use non-PVC tubing and 0.2 or 0.22 micron in-line filter
during administration
CISplatin (PLATINOL) 49 mg in sodium chloride 0.9 % 1,000 mL bag
49 mg (25 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 24 HOURS, 4 doses Starting S+1 at
0000
For 60 to 120 minutes.
mesna (MESNEX) 980 mg in sodium chloride 0.9 % 50 mL bag
980 mg (500 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, 12 doses Starting S+1 at 0000
Give prior to ifosfamide and 4 hours and 8 hours after start of ifosfamide infusion on Day 2 through 5. If patient discharged prior to
completing all IV mesna doses, remaining doses must be given orally as take home medication (oral dose = 2 X IV dose).
ifosfamide (IFEX) 2,940 mg in sodium chloride 0.9 % 250 mL bag
2,940 mg (1,500 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 24 HOURS, 4 doses Starting
S+1 at 0000
Conditional Orders
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
If unable to take PO, may give IV.
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting, If unable to tolerate PO.
IV push slowly, max rate 5 mg/minute.
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 6, 7, and 8., 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
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, 1 X DAILY PRN, 2 doses Starting S+1 at 0000, Urine output less than 400 mL per 4 hour period.
Day 2: Administer one dose. Notify MD if additional dose is required. IV push rate 10 mg/minute. IV infusion rate 4 mg/minute.
Take Home Medications (delete all that do not apply)
mesna (MESNEX) 400 MG tab
Take 5 tabs by mouth 2 times daily. Take 4 & 8 hours after start of last dose of ifosfamide, 2,000 mg (rounded from 1,960 mg =
1,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
Order if patient has not completed all inpatient IV mesna doses. Oral dose = 2 X IV dose. Round dose to nearest 200 mg.
Follow-Up
MULTIPLE DAY FOLLOW-UP (1)
DAY 8 AND 15 (if needed): LABS: Alpha-Fetoprotein, Quantitative HCG, Total LD.
DAY 10 FOLLOW-UP
LABS: CBC without DIFF, ANC (CBC with DIFF if drawn locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) Schedule preadmission to B6/6 for chemotherapy administration.
Day 10 (Lab Only), Cycle 1 – Planned for 6/24/2017
Treatment Plan Information
Reference Information (1)
TESTICULAR CANCER: Kondagunta G, et al. J Clin Oncol. 2005; 23(27):6549-55
Treatment Plan Summary
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Zztestonc,Jeff J [2507481]
6/15/2017 8:06:57 AM Page 4 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

DISEASE: Testicular Cancer (Advanced); THERAPY: PACLItaxel 250 mg/m2 IV continuous infusion over 24 hours Day 1, CISplatin
25 mg/m2 IV Day 2 through 5, mesna 500 mg/m2 IV prior to ifosfamide and 4 hours and 8 hours after start of ifosfamide Day 2
through 5, ifosfamide 1500 mg/m2 IV Day 2 through 5; CYCLE LENGTH: 21 days; COURSE: 4 cycles; NOTE: If patient is
discharged early, order oral mesna (oral dose = 2 X IV dose) for remaining doses
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 Approximate, Expires-S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Normal, Routine
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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 7/6/2017 through 7/26/2017 (21 days), Planned
Day 1, Cycle 2 – Planned for 7/6/2017
Treatment Plan Information
Reference Information (1)
TESTICULAR CANCER: Kondagunta G, et al. J Clin Oncol. 2005; 23(27):6549-55
Treatment Plan Summary
DISEASE: Testicular Cancer (Advanced); THERAPY: PACLItaxel 250 mg/m2 IV continuous infusion over 24 hours Day 1, CISplatin
25 mg/m2 IV Day 2 through 5, mesna 500 mg/m2 IV prior to ifosfamide and 4 hours and 8 hours after start of ifosfamide Day 2
through 5, ifosfamide 1500 mg/m2 IV Day 2 through 5; CYCLE LENGTH: 21 days; COURSE: 4 cycles; NOTE: If patient is
discharged early, order oral mesna (oral dose = 2 X IV dose) for remaining doses
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
ONCE Starting when released
ABSOLUTE NEUTROPHIL COUNT
ONCE Starting when released
ELECTROLYTES
ONCE Starting when released
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Zztestonc,Jeff J [2507481]
6/15/2017 8:06:57 AM Page 5 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

BUN
ONCE Starting when released
CREATININE
ONCE Starting when released
MAGNESIUM
ONCE Starting when released
BILIRUBIN, TOTAL
ONCE Starting when released
AST/SGOT
ONCE Starting when released
ALT/SGPT
ONCE Starting when released
ALBUMIN
ONCE Starting when released
URINALYSIS WITH MICROSCOPY
NEXT AM Starting S+1 As Scheduled for 5 occurrences
AFP, TUMOR MARKER, SERUM
ONCE Starting when released
HCG, QUANTITATIVE
ONCE Starting when released, Routine
LD, TOTAL
ONCE Starting when released
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained on Day 1: ANC, Platelets, Creatinine, Total Bilirubin, AST, ALT, Albumin
Verify Labs (2)
Verify pretreatment labs have been obtained on Day 2 through 5: Urinalysis
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL, Platelets less than 75K/µL, Creatinine greater than 2
mg/dL or Creatinine Clearance less than 50 mL/min, Total Bilirubin greater than 2 mg/dL, AST or ALT greater than 3 X ULN or
Albumin less than 3 gm/dL.
Treatment Parameters (2)
Hold treatment and notify authorizing prescriber for Urine Hemoglobin greater than Trace prior to ifosfamide administration on Day 2
through 5.
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.
Vital Signs
SEE COMMENTS Starting when released Until Specified
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.
Monitoring Parameters (1)
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Zztestonc,Jeff J [2507481]
6/15/2017 8:06:57 AM Page 6 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Monitor for ifosfamide-related neurotoxicity (somnolence, agitation, confusion, delirium, hallucinations, incontinence,
palsy, diplopia or aphasia). Stop infusion and contact physician if toxicity is suspected.
Monitoring Parameters (2)
Monitor and notify physician for signs and symptoms of hemorrhagic cystitis (dysuria).
Measure Intake And Output
EVERY 4 HOURS Starting S+1 at 0000 Until Specified
Measure IV intake and urine output.
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 100 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
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.
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, EVERY 24 HOURS, 4 doses Starting S+1 at 0000
Give prior to chemotherapy. May give IV if unable to tolerate PO.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, EVERY 24 HOURS PRN, 4 doses Starting S+1 at 0000, nausea/vomiting
Give prior to chemotherapy if patient unable to tolerate PO.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, EVERY 24 HOURS, 4 doses Starting S+1 at 0000
Give prior to chemotherapy. May give IV if unable to tolerate PO.
dexamethasone (DECADRON) 10 MG/ML injection 8 mg
8 mg, Intravenous, EVERY 24 HOURS PRN, For 5 days Starting S+1 at 0000, nausea/vomiting
Give prior to chemotherapy if patient unable to tolerate PO.
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
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Zztestonc,Jeff J [2507481]
6/15/2017 8:06:57 AM Page 7 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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) 490 mg in dextrose 5 % 500 mL non-PVC bag
490 mg (250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Infuse over 24 hours. Use non-PVC tubing and 0.2 or 0.22 micron in-line filter
during administration
CISplatin (PLATINOL) 49 mg in sodium chloride 0.9 % 1,000 mL bag
49 mg (25 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 24 HOURS, 4 doses Starting S+1 at
0000
For 60 to 120 minutes.
mesna (MESNEX) 980 mg in sodium chloride 0.9 % 50 mL bag
980 mg (500 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, 12 doses Starting S+1 at 0000
Give prior to ifosfamide and 4 hours and 8 hours after start of ifosfamide infusion on Day 2 through 5. If patient discharged prior to
completing all IV mesna doses, remaining doses must be given orally as take home medication (oral dose = 2 X IV dose).
ifosfamide (IFEX) 2,940 mg in sodium chloride 0.9 % 250 mL bag
2,940 mg (1,500 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 24 HOURS, 4 doses Starting
S+1 at 0000
Conditional Orders
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
If unable to take PO, may give IV.
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting, If unable to tolerate PO.
IV push slowly, max rate 5 mg/minute.
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, 1 X DAILY PRN, 2 doses Starting S+1 at 0000, Urine output less than 400 mL per 4 hour period.
Day 2: Administer one dose. Notify MD if additional dose is required. IV push rate 10 mg/minute. IV infusion rate 4 mg/minute.
Take Home Medications (delete all that do not apply)
mesna (MESNEX) 400 MG tab
Take 5 tabs by mouth 2 times daily. Take 4 & 8 hours after start of last dose of ifosfamide, 2,000 mg (rounded from 1,960 mg =
1,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
Order if patient has not completed all inpatient IV mesna doses. Oral dose = 2 X IV dose. Round dose to nearest 200 mg.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC without DIFF, ANC (CBC with DIFF if drawn locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) Schedule preadmission to B6/6 for chemotherapy administration.
Day 10 (Lab Only), Cycle 2 – Planned for 7/15/2017
Treatment Plan Information
Reference Information (1)
TESTICULAR CANCER: Kondagunta G, et al. J Clin Oncol. 2005; 23(27):6549-55
Treatment Plan Summary
DISEASE: Testicular Cancer (Advanced); THERAPY: PACLItaxel 250 mg/m2 IV continuous infusion over 24 hours Day 1, CISplatin
25 mg/m2 IV Day 2 through 5, mesna 500 mg/m2 IV prior to ifosfamide and 4 hours and 8 hours after start of ifosfamide Day 2
through 5, ifosfamide 1500 mg/m2 IV Day 2 through 5; CYCLE LENGTH: 21 days; COURSE: 4 cycles; NOTE: If patient is
discharged early, order oral mesna (oral dose = 2 X IV dose) for remaining doses
IV Access
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Zztestonc,Jeff J [2507481]
6/15/2017 8:06:57 AM Page 8 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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 Approximate, Expires-S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Normal, Routine
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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 – 7/27/2017 through 8/16/2017 (21 days), Planned
Day 1, Cycle 3 – Planned for 7/27/2017
Treatment Plan Information
Reference Information (1)
TESTICULAR CANCER: Kondagunta G, et al. J Clin Oncol. 2005; 23(27):6549-55
Treatment Plan Summary
DISEASE: Testicular Cancer (Advanced); THERAPY: PACLItaxel 250 mg/m2 IV continuous infusion over 24 hours Day 1, CISplatin
25 mg/m2 IV Day 2 through 5, mesna 500 mg/m2 IV prior to ifosfamide and 4 hours and 8 hours after start of ifosfamide Day 2
through 5, ifosfamide 1500 mg/m2 IV Day 2 through 5; CYCLE LENGTH: 21 days; COURSE: 4 cycles; NOTE: If patient is
discharged early, order oral mesna (oral dose = 2 X IV dose) for remaining doses
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
ONCE Starting when released
ABSOLUTE NEUTROPHIL COUNT
ONCE Starting when released
ELECTROLYTES
ONCE Starting when released
BUN
ONCE Starting when released
CREATININE
ONCE Starting when released
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Zztestonc,Jeff J [2507481]
6/15/2017 8:06:57 AM Page 9 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

MAGNESIUM
ONCE Starting when released
BILIRUBIN, TOTAL
ONCE Starting when released
AST/SGOT
ONCE Starting when released
ALT/SGPT
ONCE Starting when released
ALBUMIN
ONCE Starting when released
URINALYSIS WITH MICROSCOPY
NEXT AM Starting S+1 As Scheduled for 5 occurrences
AFP, TUMOR MARKER, SERUM
ONCE Starting when released
HCG, QUANTITATIVE
ONCE Starting when released, Routine
LD, TOTAL
ONCE Starting when released
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained on Day 1: ANC, Platelets, Creatinine, Total Bilirubin, AST, ALT, Albumin
Verify Labs (2)
Verify pretreatment labs have been obtained on Day 2 through 5: Urinalysis
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL, Platelets less than 75K/µL, Creatinine greater than 2
mg/dL or Creatinine Clearance less than 50 mL/min, Total Bilirubin greater than 2 mg/dL, AST or ALT greater than 3 X ULN or
Albumin less than 3 gm/dL.
Treatment Parameters (2)
Hold treatment and notify authorizing prescriber for Urine Hemoglobin greater than Trace prior to ifosfamide administration on Day 2
through 5.
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.
Vital Signs
SEE COMMENTS Starting when released Until Specified
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.
Monitoring Parameters (1)
Monitor for ifosfamide-related neurotoxicity (somnolence, agitation, confusion, delirium, hallucinations, incontinence, palsy, diplopia
or aphasia). Stop infusion and contact physician if toxicity is suspected.
Monitoring Parameters (2)
Monitor and notify physician for signs and symptoms of hemorrhagic cystitis (dysuria).
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Zztestonc,Jeff J [2507481]
6/15/2017 8:06:57 AM Page 10 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Measure Intake And Output
EVERY 4 HOURS Starting S+1 at 0000 Until Specified
Measure IV intake and urine output.
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 100 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
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.
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, EVERY 24 HOURS, 4 doses Starting S+1 at 0000
Give prior to chemotherapy. May give IV if unable to tolerate PO.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, EVERY 24 HOURS PRN, 4 doses Starting S+1 at 0000, nausea/vomiting
Give prior to chemotherapy if patient unable to tolerate PO.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, EVERY 24 HOURS, 4 doses Starting S+1 at 0000
Give prior to chemotherapy. May give IV if unable to tolerate PO.
dexamethasone (DECADRON) 10 MG/ML injection 8 mg
8 mg, Intravenous, EVERY 24 HOURS PRN, For 5 days Starting S+1 at 0000, nausea/vomiting
Give prior to chemotherapy if patient unable to tolerate PO.
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
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Zztestonc,Jeff J [2507481]
6/15/2017 8:06:57 AM Page 11 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 490 mg in dextrose 5 % 500 mL non-PVC bag
490 mg (250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Infuse over 24 hours. Use non-PVC tubing and 0.2 or 0.22 micron in-line filter
during administration
CISplatin (PLATINOL) 49 mg in sodium chloride 0.9 % 1,000 mL bag
49 mg (25 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 24 HOURS, 4 doses Starting S+1 at
0000
For 60 to 120 minutes.
mesna (MESNEX) 980 mg in sodium chloride 0.9 % 50 mL bag
980 mg (500 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, 12 doses Starting S+1 at 0000
Give prior to ifosfamide and 4 hours and 8 hours after start of ifosfamide infusion on Day 2 through 5. If patient discharged prior to
completing all IV mesna doses, remaining doses must be given orally as take home medication (oral dose = 2 X IV dose).
ifosfamide (IFEX) 2,940 mg in sodium chloride 0.9 % 250 mL bag
2,940 mg (1,500 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 24 HOURS, 4 doses Starting
S+1 at 0000
Conditional Orders
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
If unable to take PO, may give IV.
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting, If unable to tolerate PO.
IV push slowly, max rate 5 mg/minute.
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, 1 X DAILY PRN, 2 doses Starting S+1 at 0000, Urine output less than 400 mL per 4 hour period.
Day 2: Administer one dose. Notify MD if additional dose is required. IV push rate 10 mg/minute. IV infusion rate 4 mg/minute.
Take Home Medications (delete all that do not apply)
mesna (MESNEX) 400 MG tab
Take 5 tabs by mouth 2 times daily. Take 4 & 8 hours after start of last dose of ifosfamide, 2,000 mg (rounded from 1,960 mg =
1,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
Order if patient has not completed all inpatient IV mesna doses. Oral dose = 2 X IV dose. Round dose to nearest 200 mg.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC without DIFF, ANC (CBC with DIFF if drawn locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) Schedule preadmission to B6/6 for chemotherapy administration.
Day 10 (Lab Only), Cycle 3 – Planned for 8/5/2017
Treatment Plan Information
Reference Information (1)
TESTICULAR CANCER: Kondagunta G, et al. J Clin Oncol. 2005; 23(27):6549-55
Treatment Plan Summary
DISEASE: Testicular Cancer (Advanced); THERAPY: PACLItaxel 250 mg/m2 IV continuous infusion over 24 hours Day 1, CISplatin
25 mg/m2 IV Day 2 through 5, mesna 500 mg/m2 IV prior to ifosfamide and 4 hours and 8 hours after start of ifosfamide Day 2
through 5, ifosfamide 1500 mg/m2 IV Day 2 through 5; CYCLE LENGTH: 21 days; COURSE: 4 cycles; NOTE: If patient is
discharged early, order oral mesna (oral dose = 2 X IV dose) for remaining doses
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,Jeff J [2507481]
6/15/2017 8:06:57 AM Page 12 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

CBC WITHOUT DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Normal, Routine
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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 – 8/17/2017 through 9/6/2017 (21 days), Planned
Day 1, Cycle 4 – Planned for 8/17/2017
Treatment Plan Information
Reference Information (1)
TESTICULAR CANCER: Kondagunta G, et al. J Clin Oncol. 2005; 23(27):6549-55
Treatment Plan Summary
DISEASE: Testicular Cancer (Advanced); THERAPY: PACLItaxel 250 mg/m2 IV continuous infusion over 24 hours Day 1, CISplatin
25 mg/m2 IV Day 2 through 5, mesna 500 mg/m2 IV prior to ifosfamide and 4 hours and 8 hours after start of ifosfamide Day 2
through 5, ifosfamide 1500 mg/m2 IV Day 2 through 5; CYCLE LENGTH: 21 days; COURSE: 4 cycles; NOTE: If patient is
discharged early, order oral mesna (oral dose = 2 X IV dose) for remaining doses
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
ONCE Starting when released
ABSOLUTE NEUTROPHIL COUNT
ONCE Starting when released
ELECTROLYTES
ONCE Starting when released
BUN
ONCE Starting when released
CREATININE
ONCE Starting when released
MAGNESIUM
ONCE Starting when released
BILIRUBIN, TOTAL
ONCE Starting when released
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Zztestonc,Jeff J [2507481]
6/15/2017 8:06:57 AM Page 13 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

AST/SGOT
ONCE Starting when released
ALT/SGPT
ONCE Starting when released
ALBUMIN
ONCE Starting when released
URINALYSIS WITH MICROSCOPY
NEXT AM Starting S+1 As Scheduled for 5 occurrences
AFP, TUMOR MARKER, SERUM
ONCE Starting when released
HCG, QUANTITATIVE
ONCE Starting when released, Routine
LD, TOTAL
ONCE Starting when released
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained on Day 1: ANC, Platelets, Creatinine, Total Bilirubin, AST, ALT, Albumin
Verify Labs (2)
Verify pretreatment labs have been obtained on Day 2 through 5: Urinalysis
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL, Platelets less than 75K/µL, Creatinine greater than 2
mg/dL or Creatinine Clearance less than 50 mL/min, Total Bilirubin greater than 2 mg/dL, AST or ALT greater than 3 X ULN or
Albumin less than 3 gm/dL.
Treatment Parameters (2)
Hold treatment and notify authorizing prescriber for Urine Hemoglobin greater than Trace prior to ifosfamide administration on Day 2
through 5.
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.
Vital Signs
SEE COMMENTS Starting when released Until Specified
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.
Monitoring Parameters (1)
Monitor for ifosfamide-related neurotoxicity (somnolence, agitation, confusion, delirium, hallucinations, incontinence, palsy, diplopia
or aphasia). Stop infusion and contact physician if toxicity is suspected.
Monitoring Parameters (2)
Monitor and notify physician for signs and symptoms of hemorrhagic cystitis (dysuria).
Measure Intake And Output
EVERY 4 HOURS Starting S+1 at 0000 Until Specified
Measure IV intake and urine output.
Flush Venous Access Device per Guidelines
Order details
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Zztestonc,Jeff J [2507481]
6/15/2017 8:06:57 AM Page 14 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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 100 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
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.
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, EVERY 24 HOURS, 4 doses Starting S+1 at 0000
Give prior to chemotherapy. May give IV if unable to tolerate PO.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, EVERY 24 HOURS PRN, 4 doses Starting S+1 at 0000, nausea/vomiting
Give prior to chemotherapy if patient unable to tolerate PO.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, EVERY 24 HOURS, 4 doses Starting S+1 at 0000
Give prior to chemotherapy. May give IV if unable to tolerate PO.
dexamethasone (DECADRON) 10 MG/ML injection 8 mg
8 mg, Intravenous, EVERY 24 HOURS PRN, For 5 days Starting S+1 at 0000, nausea/vomiting
Give prior to chemotherapy if patient unable to tolerate PO.
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) 490 mg in dextrose 5 % 500 mL non-PVC bag
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Zztestonc,Jeff J [2507481]
6/15/2017 8:06:57 AM Page 15 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

490 mg (250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Infuse over 24 hours. Use non-PVC tubing and 0.2 or 0.22 micron in-line filter
during administration
CISplatin (PLATINOL) 49 mg in sodium chloride 0.9 % 1,000 mL bag
49 mg (25 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 24 HOURS, 4 doses Starting S+1 at
0000
For 60 to 120 minutes.
mesna (MESNEX) 980 mg in sodium chloride 0.9 % 50 mL bag
980 mg (500 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, 12 doses Starting S+1 at 0000
Give prior to ifosfamide and 4 hours and 8 hours after start of ifosfamide infusion on Day 2 through 5. If patient discharged prior to
completing all IV mesna doses, remaining doses must be given orally as take home medication (oral dose = 2 X IV dose).
ifosfamide (IFEX) 2,940 mg in sodium chloride 0.9 % 250 mL bag
2,940 mg (1,500 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 24 HOURS, 4 doses Starting
S+1 at 0000
Conditional Orders
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
If unable to take PO, may give IV.
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting, If unable to tolerate PO.
IV push slowly, max rate 5 mg/minute.
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, 1 X DAILY PRN, 2 doses Starting S+1 at 0000, Urine output less than 400 mL per 4 hour period.
Day 2: Administer one dose. Notify MD if additional dose is required. IV push rate 10 mg/minute. IV infusion rate 4 mg/minute.
Take Home Medications (delete all that do not apply)
mesna (MESNEX) 400 MG tab
Take 5 tabs by mouth 2 times daily. Take 4 & 8 hours after start of last dose of ifosfamide, 2,000 mg (rounded from 1,960 mg =
1,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
Order if patient has not completed all inpatient IV mesna doses. Oral dose = 2 X IV dose. Round dose to nearest 200 mg.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC without DIFF, ANC (CBC with DIFF if drawn locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) Schedule preadmission to B6/6 for chemotherapy administration.
Day 10 (Lab Only), Cycle 4 – Planned for 8/26/2017
Treatment Plan Information
Reference Information (1)
TESTICULAR CANCER: Kondagunta G, et al. J Clin Oncol. 2005; 23(27):6549-55
Treatment Plan Summary
DISEASE: Testicular Cancer (Advanced); THERAPY: PACLItaxel 250 mg/m2 IV continuous infusion over 24 hours Day 1, CISplatin
25 mg/m2 IV Day 2 through 5, mesna 500 mg/m2 IV prior to ifosfamide and 4 hours and 8 hours after start of ifosfamide Day 2
through 5, ifosfamide 1500 mg/m2 IV Day 2 through 5; CYCLE LENGTH: 21 days; COURSE: 4 cycles; NOTE: If patient is
discharged early, order oral mesna (oral dose = 2 X IV dose) for remaining doses
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 Approximate, Expires-S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
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Zztestonc,Jeff J [2507481]
6/15/2017 8:06:57 AM Page 16 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Expected-S Approximate, Expires-S+365, Normal, Routine
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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,Jeff J [2507481]
6/15/2017 8:06:57 AM Page 17 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org