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

/clinical/cckm-tools/content/beacon-protocols/gu/name-96696-en.cckm

201706166

page

100

UWHC,UWMF,

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

CSC GU OUTPT Tip Cisplatin(21D:1-5) Ifosfamide(21D:1-5) Paclitaxel(21D:1) (Testicular) VER 12-1-16 (HL 711)

CSC GU OUTPT Tip Cisplatin(21D:1-5) Ifosfamide(21D:1-5) Paclitaxel(21D:1) (Testicular) VER 12-1-16 (HL 711) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GU


CSC GU OUTPT TIP CISPLATIN(21D1-5)IFOSFAMIDE(21D1-5)PACLITAXEL(21D1) (TESTICULAR) VER 12-1-16 (HL
711) – Properties
Pre-Cycle – 6/8/2017 through 6/14/2017 (7 days), Planned
Day 1, Pre-Cycle – Planned for 6/8/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular/Germ Cell Cancer (Advanced); THERAPY: PACLItaxel 175 mg/m2 IV Day 1, mesna 500 mg/m2 IV at start of
ifosfamide followed by mesna 500 mg/m2 IV or by mouth 4 and 8 hours after the start of ifosfamide Day 1 through 5, ifosfamide
1000 mg/m2 IV Day 1 through 5; CISplatin 20 mg/m2 IV Day 1 through 5, CYCLE LENGTH: 21 days; COURSE: 2-4 cycles. NOTE:
mesna dose varies from reference.
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
POTASSIUM
Expected-S Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
AFP, TUMOR MARKER, SERUM
Expected-S Approximate, Expires-S+365, Normal, Routine
HCG, QUANTITATIVE
Expected-S Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S Approximate, Expires-S+365, Routine
URINALYSIS, NO MICROSCOPY
Expected-S Approximate, Expires-S+365, Normal, 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 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
Take Home Medications (delete all that do not apply)
TBO-filgrastim (GRANIX) 300 MCG/0.5ML soln prefilled syringe
Inject 300 mcg under skin one time daily in evening. Begin Day ***. Continue until ANC is greater than *** after nadir., 300 mcg,
Disp-10 Syringe, R-5, 1 X DAILY (PM) starting S, Local Printer
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
TBO-filgrastim (GRANIX) 480 MCG/0.8ML soln prefilled syringe
Inject 480 mcg under skin one time daily in evening. Begin Day ***. Continue until ANC is greater than *** after nadir., 480 mcg,
Disp-10 Syringe, R-5, 1 X DAILY (PM) starting S, Local Printer
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/15/2017 7:43:52 AM Page 1 of 36
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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/GERM CELL CANCER: Mead GM, et al. B J Cancer 2005: 174-8.
Treatment Plan Summary
DISEASE: Testicular/Germ Cell Cancer (Advanced); THERAPY: PACLItaxel 175 mg/m2 IV Day 1, mesna 500 mg/m2 IV at start of
ifosfamide followed by mesna 500 mg/m2 IV or by mouth 4 and 8 hours after the start of ifosfamide Day 1 through 5, ifosfamide
1000 mg/m2 IV Day 1 through 5; CISplatin 20 mg/m2 IV Day 1 through 5, CYCLE LENGTH: 21 days; COURSE: 2-4 cycles. NOTE:
mesna dose varies from reference.
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.
Additional Labs (delete all that do not apply)
AFP, TUMOR MARKER, SERUM
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 and resulted: WBC, ANC, Platelets, Creatinine, Urine Heme.
Monitoring Parameters (1)
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL or Urine
Hemoglobin greater than Trace or Creatinine greater than upper limits of normal.
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. See Emergency Medications.
** Rush dextrose primed line with 18 mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/15/2017 7:43:52 AM Page 2 of 36
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

** 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
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
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
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Give 30 minutes prior to treatment.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Give 30 minutes prior to treatment
palonosetron (ALOXI) injection 0.25 mg
0.25 mg, Intravenous, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
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
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.
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/15/2017 7:43:52 AM Page 3 of 36
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

PACLItaxel (TAXOL) 343 mg in dextrose 5 % 500 mL non-PVC bag
343 mg (175 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 180 minutes. Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications. Use non-PVC tubing and 0.2 or 0.22 micron in-line filter during administration.
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, ONCE, 1 dose Starting when released
Give prior to start of ifosfamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
ifosfamide (IFEX) 1,960 mg in sodium chloride 0.9 % 500 mL bag
1,960 mg (1,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
CISplatin (PLATINOL) 39 mg in sodium chloride 0.9 % 1,000 mL bag
39 mg (rounded from 39.2 mg = 20 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60 minutes.
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Take Home Medications
mesna (MESNEX) 400 MG tab
Take 2.5 tabs by mouth 2 times daily. Take 4 & 8 hours after start of ifosfamide Day 1 thru 5., 1,000 mg (rounded from 980 mg =
500 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
Follow-Up
DAY 2 FOLLOW-UP
LABS: Urinalysis without microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide, mesna, CISplatin for 200 minutes.
DAY 3 FOLLOW-UP
LABS: Urinalysis without microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide, mesna, CISplatin for 200 minutes.
DAY 4 FOLLOW-UP
LABS: Creatinine, Phosphate, Magnesium, Potassium, Urinalysis without microscopy; CHEMOTHERAPY ROOM APPOINTMENT:
ifosfamide, mesna, CISplatin for 200 minutes.
DAY 5 FOLLOW-UP
LABS: Urinalysis without microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide, mesna, CISplatin for 200 minutes.
MULTIPLE DAY FOLLOW-UP (1)
DAY 8 AND 15: LABS: CBC, ANC (DIFF if to be done locally); LABS (if needed): Alpha-Fetoprotein, Quantitative HCG, Total LD.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Potassium,
Magnesium, Creatinine, Urinalysis without microscopy, Alpha-Fetoprotein, Quantitative HCG, Total LD; CHEMOTHERAPY ROOM
APPOINTMENT: PACLItaxel, ifosfamide, mesna, CISplatin for 300 minutes.
Day 2, Cycle 1 – Planned for 6/16/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular/Germ Cell Cancer (Advanced); THERAPY: PACLItaxel 175 mg/m2 IV Day 1, mesna 500 mg/m2 IV at start of
ifosfamide followed by mesna 500 mg/m2 IV or by mouth 4 and 8 hours after the start of ifosfamide Day 1 through 5, ifosfamide
1000 mg/m2 IV Day 1 through 5; CISplatin 20 mg/m2 IV Day 1 through 5, CYCLE LENGTH: 21 days; COURSE: 2-4 cycles. NOTE:
mesna dose varies from reference.
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/15/2017 7:43:52 AM Page 4 of 36
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

URINALYSIS, NO MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: Urine Heme.
Treatment Parameters
Hold and notify authorizing prescriber for Urine Hemoglobin greater than Trace.
Nursing Procedure, Assessment and Monitoring
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
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
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
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, ONCE, 1 dose Starting when released
Give prior to start of ifosfamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
ifosfamide (IFEX) 1,960 mg in sodium chloride 0.9 % 500 mL bag
1,960 mg (1,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
CISplatin (PLATINOL) 39 mg in sodium chloride 0.9 % 1,000 mL bag
39 mg (rounded from 39.2 mg = 20 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60 minutes.
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 1 – Planned for 6/17/2017
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/15/2017 7:43:52 AM Page 5 of 36
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular/Germ Cell Cancer (Advanced); THERAPY: PACLItaxel 175 mg/m2 IV Day 1, mesna 500 mg/m2 IV at start of
ifosfamide followed by mesna 500 mg/m2 IV or by mouth 4 and 8 hours after the start of ifosfamide Day 1 through 5, ifosfamide
1000 mg/m2 IV Day 1 through 5; CISplatin 20 mg/m2 IV Day 1 through 5, CYCLE LENGTH: 21 days; COURSE: 2-4 cycles. NOTE:
mesna dose varies from reference.
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
URINALYSIS, NO MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: Urine Heme.
Treatment Parameters
Hold and notify authorizing prescriber for Urine Hemoglobin greater than Trace.
Nursing Procedure, Assessment and Monitoring
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
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
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
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, ONCE, 1 dose Starting when released
Give prior to start of ifosfamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
ifosfamide (IFEX) 1,960 mg in sodium chloride 0.9 % 500 mL bag
1,960 mg (1,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
CISplatin (PLATINOL) 39 mg in sodium chloride 0.9 % 1,000 mL bag
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/15/2017 7:43:52 AM Page 6 of 36
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

39 mg (rounded from 39.2 mg = 20 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60 minutes.
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 4, Cycle 1 – Planned for 6/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular/Germ Cell Cancer (Advanced); THERAPY: PACLItaxel 175 mg/m2 IV Day 1, mesna 500 mg/m2 IV at start of
ifosfamide followed by mesna 500 mg/m2 IV or by mouth 4 and 8 hours after the start of ifosfamide Day 1 through 5, ifosfamide
1000 mg/m2 IV Day 1 through 5; CISplatin 20 mg/m2 IV Day 1 through 5, CYCLE LENGTH: 21 days; COURSE: 2-4 cycles. NOTE:
mesna dose varies from reference.
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
CREATININE
Expected-S+1 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+1 Approximate, Expires-S+365, Normal, Routine
MAGNESIUM
Expected-S+1 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+1 Approximate, Expires-S+365, Routine
URINALYSIS, NO MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: Urine Heme.
Treatment Parameters
Hold and notify authorizing prescriber for Urine Hemoglobin greater than Trace.
Nursing Procedure, Assessment and Monitoring
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/15/2017 7:43:52 AM Page 7 of 36
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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
palonosetron (ALOXI) injection 0.25 mg
0.25 mg, Intravenous, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
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, ONCE, 1 dose Starting when released
Give prior to start of ifosfamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
ifosfamide (IFEX) 1,960 mg in sodium chloride 0.9 % 500 mL bag
1,960 mg (1,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
CISplatin (PLATINOL) 39 mg in sodium chloride 0.9 % 1,000 mL bag
39 mg (rounded from 39.2 mg = 20 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60 minutes.
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 1 – Planned for 6/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular/Germ Cell Cancer (Advanced); THERAPY: PACLItaxel 175 mg/m2 IV Day 1, mesna 500 mg/m2 IV at start of
ifosfamide followed by mesna 500 mg/m2 IV or by mouth 4 and 8 hours after the start of ifosfamide Day 1 through 5, ifosfamide
1000 mg/m2 IV Day 1 through 5; CISplatin 20 mg/m2 IV Day 1 through 5, CYCLE LENGTH: 21 days; COURSE: 2-4 cycles. NOTE:
mesna dose varies from reference.
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
URINALYSIS, NO MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/15/2017 7:43:52 AM Page 8 of 36
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Verify pretreatment labs have been obtained and resulted: Urine Heme.
Treatment Parameters
Hold and notify authorizing prescriber for Urine Hemoglobin greater than Trace.
Nursing Procedure, Assessment and Monitoring
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
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
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
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, ONCE, 1 dose Starting when released
Give prior to start of ifosfamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
ifosfamide (IFEX) 1,960 mg in sodium chloride 0.9 % 500 mL bag
1,960 mg (1,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
CISplatin (PLATINOL) 39 mg in sodium chloride 0.9 % 1,000 mL bag
39 mg (rounded from 39.2 mg = 20 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60 minutes.
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 8, Cycle 1 – Planned for 6/22/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular/Germ Cell Cancer (Advanced); THERAPY: PACLItaxel 175 mg/m2 IV Day 1, mesna 500 mg/m2 IV at start of
ifosfamide followed by mesna 500 mg/m2 IV or by mouth 4 and 8 hours after the start of ifosfamide Day 1 through 5, ifosfamide
1000 mg/m2 IV Day 1 through 5; CISplatin 20 mg/m2 IV Day 1 through 5, CYCLE LENGTH: 21 days; COURSE: 2-4 cycles. NOTE:
mesna dose varies from reference.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/15/2017 7:43:52 AM Page 9 of 36
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@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+3 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+3 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 1 – Planned for 6/29/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular/Germ Cell Cancer (Advanced); THERAPY: PACLItaxel 175 mg/m2 IV Day 1, mesna 500 mg/m2 IV at start of
ifosfamide followed by mesna 500 mg/m2 IV or by mouth 4 and 8 hours after the start of ifosfamide Day 1 through 5, ifosfamide
1000 mg/m2 IV Day 1 through 5; CISplatin 20 mg/m2 IV Day 1 through 5, CYCLE LENGTH: 21 days; COURSE: 2-4 cycles. NOTE:
mesna dose varies from reference.
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+10 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+10 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 – 7/6/2017 through 7/26/2017 (21 days), Planned
Day 1, Cycle 2 – Planned for 7/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular/Germ Cell Cancer (Advanced); THERAPY: PACLItaxel 175 mg/m2 IV Day 1, mesna 500 mg/m2 IV at start of
ifosfamide followed by mesna 500 mg/m2 IV or by mouth 4 and 8 hours after the start of ifosfamide Day 1 through 5, ifosfamide
1000 mg/m2 IV Day 1 through 5; CISplatin 20 mg/m2 IV Day 1 through 5, CYCLE LENGTH: 21 days; COURSE: 2-4 cycles. NOTE:
mesna dose varies from reference.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/15/2017 7:43:52 AM Page 10 of 36
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@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+17 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+17 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+17 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+17 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+17 Approximate, Expires-S+365, Routine
AFP, TUMOR MARKER, SERUM
Expected-S+17 Approximate, Expires-S+365, Normal, Routine
HCG, QUANTITATIVE
Expected-S+17 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+17 Approximate, Expires-S+365, Routine
URINALYSIS, NO MICROSCOPY
Expected-S+17 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, Urine Heme.
Monitoring Parameters (1)
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL or Urine
Hemoglobin greater than Trace or Creatinine greater than upper limits of normal.
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. See Emergency Medications.
** Rush dextrose primed line with 18 mL 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
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/15/2017 7:43:52 AM Page 11 of 36
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Give 30 minutes prior to treatment.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Give 30 minutes prior to treatment
palonosetron (ALOXI) injection 0.25 mg
0.25 mg, Intravenous, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
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
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) 343 mg in dextrose 5 % 500 mL non-PVC bag
343 mg (175 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 180 minutes. Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications. Use non-PVC tubing and 0.2 or 0.22 micron in-line filter during administration.
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, ONCE, 1 dose Starting when released
Give prior to start of ifosfamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
ifosfamide (IFEX) 1,960 mg in sodium chloride 0.9 % 500 mL bag
1,960 mg (1,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
CISplatin (PLATINOL) 39 mg in sodium chloride 0.9 % 1,000 mL bag
39 mg (rounded from 39.2 mg = 20 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60 minutes.
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/15/2017 7:43:52 AM Page 12 of 36
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Take Home Medications
mesna (MESNEX) 400 MG tab
Take 2.5 tabs by mouth 2 times daily. Take 4 & 8 hours after start of ifosfamide Day 1 thru 5., 1,000 mg (rounded from 980 mg =
500 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
Follow-Up
DAY 2 FOLLOW-UP
LABS: Urinalysis without microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide, mesna, CISplatin for 200 minutes.
DAY 3 FOLLOW-UP
LABS: Urinalysis without microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide, mesna, CISplatin for 200 minutes.
DAY 4 FOLLOW-UP
LABS: Creatinine, Phosphate, Magnesium, Potassium, Urinalysis without microscopy; CHEMOTHERAPY ROOM APPOINTMENT:
ifosfamide, mesna, CISplatin for 200 minutes.
DAY 5 FOLLOW-UP
LABS: Urinalysis without microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide, mesna, CISplatin for 200 minutes.
MULTIPLE DAY FOLLOW-UP (1)
DAY 8 AND 15 (if needed): LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Potassium,
Magnesium, Creatinine, Urinalysis without microscopy, Alpha-Fetoprotein, Quantitative HCG, Total LD; CHEMOTHERAPY ROOM
APPOINTMENT: PACLItaxel, ifosfamide, mesna, CISplatin for 300 minutes.
Day 2, Cycle 2 – Planned for 7/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular/Germ Cell Cancer (Advanced); THERAPY: PACLItaxel 175 mg/m2 IV Day 1, mesna 500 mg/m2 IV at start of
ifosfamide followed by mesna 500 mg/m2 IV or by mouth 4 and 8 hours after the start of ifosfamide Day 1 through 5, ifosfamide
1000 mg/m2 IV Day 1 through 5; CISplatin 20 mg/m2 IV Day 1 through 5, CYCLE LENGTH: 21 days; COURSE: 2-4 cycles. NOTE:
mesna dose varies from reference.
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
URINALYSIS, NO MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: Urine Heme.
Treatment Parameters
Hold and notify authorizing prescriber for Urine Hemoglobin greater than Trace.
Nursing Procedure, Assessment and Monitoring
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
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.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/15/2017 7:43:52 AM Page 13 of 36
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
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, ONCE, 1 dose Starting when released
Give prior to start of ifosfamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
ifosfamide (IFEX) 1,960 mg in sodium chloride 0.9 % 500 mL bag
1,960 mg (1,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
CISplatin (PLATINOL) 39 mg in sodium chloride 0.9 % 1,000 mL bag
39 mg (rounded from 39.2 mg = 20 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60 minutes.
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 2 – Planned for 7/8/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular/Germ Cell Cancer (Advanced); THERAPY: PACLItaxel 175 mg/m2 IV Day 1, mesna 500 mg/m2 IV at start of
ifosfamide followed by mesna 500 mg/m2 IV or by mouth 4 and 8 hours after the start of ifosfamide Day 1 through 5, ifosfamide
1000 mg/m2 IV Day 1 through 5; CISplatin 20 mg/m2 IV Day 1 through 5, CYCLE LENGTH: 21 days; COURSE: 2-4 cycles. NOTE:
mesna dose varies from reference.
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
URINALYSIS, NO MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: Urine Heme.
Treatment Parameters
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/15/2017 7:43:52 AM Page 14 of 36
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Hold and notify authorizing prescriber for Urine Hemoglobin greater than Trace.
Nursing Procedure, Assessment and Monitoring
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
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
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
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, ONCE, 1 dose Starting when released
Give prior to start of ifosfamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
ifosfamide (IFEX) 1,960 mg in sodium chloride 0.9 % 500 mL bag
1,960 mg (1,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
CISplatin (PLATINOL) 39 mg in sodium chloride 0.9 % 1,000 mL bag
39 mg (rounded from 39.2 mg = 20 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60 minutes.
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 4, Cycle 2 – Planned for 7/9/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular/Germ Cell Cancer (Advanced); THERAPY: PACLItaxel 175 mg/m2 IV Day 1, mesna 500 mg/m2 IV at start of
ifosfamide followed by mesna 500 mg/m2 IV or by mouth 4 and 8 hours after the start of ifosfamide Day 1 through 5, ifosfamide
1000 mg/m2 IV Day 1 through 5; CISplatin 20 mg/m2 IV Day 1 through 5, CYCLE LENGTH: 21 days; COURSE: 2-4 cycles. NOTE:
mesna dose varies from reference.
IV Access
Insert and Maintain Peripheral IV
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/15/2017 7:43:52 AM Page 15 of 36
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@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
CREATININE
Expected-S+1 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+1 Approximate, Expires-S+365, Normal, Routine
MAGNESIUM
Expected-S+1 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+1 Approximate, Expires-S+365, Routine
URINALYSIS, NO MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: Urine Heme.
Treatment Parameters
Hold and notify authorizing prescriber for Urine Hemoglobin greater than Trace.
Nursing Procedure, Assessment and Monitoring
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
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
palonosetron (ALOXI) injection 0.25 mg
0.25 mg, Intravenous, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
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, ONCE, 1 dose Starting when released
Give prior to start of ifosfamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
ifosfamide (IFEX) 1,960 mg in sodium chloride 0.9 % 500 mL bag
1,960 mg (1,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/15/2017 7:43:52 AM Page 16 of 36
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

CISplatin (PLATINOL) 39 mg in sodium chloride 0.9 % 1,000 mL bag
39 mg (rounded from 39.2 mg = 20 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60 minutes.
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 2 – Planned for 7/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular/Germ Cell Cancer (Advanced); THERAPY: PACLItaxel 175 mg/m2 IV Day 1, mesna 500 mg/m2 IV at start of
ifosfamide followed by mesna 500 mg/m2 IV or by mouth 4 and 8 hours after the start of ifosfamide Day 1 through 5, ifosfamide
1000 mg/m2 IV Day 1 through 5; CISplatin 20 mg/m2 IV Day 1 through 5, CYCLE LENGTH: 21 days; COURSE: 2-4 cycles. NOTE:
mesna dose varies from reference.
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
URINALYSIS, NO MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: Urine Heme.
Treatment Parameters
Hold and notify authorizing prescriber for Urine Hemoglobin greater than Trace.
Nursing Procedure, Assessment and Monitoring
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/15/2017 7:43:52 AM Page 17 of 36
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
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, ONCE, 1 dose Starting when released
Give prior to start of ifosfamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
ifosfamide (IFEX) 1,960 mg in sodium chloride 0.9 % 500 mL bag
1,960 mg (1,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
CISplatin (PLATINOL) 39 mg in sodium chloride 0.9 % 1,000 mL bag
39 mg (rounded from 39.2 mg = 20 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60 minutes.
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 8, Cycle 2 – Planned for 7/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular/Germ Cell Cancer (Advanced); THERAPY: PACLItaxel 175 mg/m2 IV Day 1, mesna 500 mg/m2 IV at start of
ifosfamide followed by mesna 500 mg/m2 IV or by mouth 4 and 8 hours after the start of ifosfamide Day 1 through 5, ifosfamide
1000 mg/m2 IV Day 1 through 5; CISplatin 20 mg/m2 IV Day 1 through 5, CYCLE LENGTH: 21 days; COURSE: 2-4 cycles. NOTE:
mesna dose varies from reference.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+3 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+3 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 2 – Planned for 7/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular/Germ Cell Cancer (Advanced); THERAPY: PACLItaxel 175 mg/m2 IV Day 1, mesna 500 mg/m2 IV at start of
ifosfamide followed by mesna 500 mg/m2 IV or by mouth 4 and 8 hours after the start of ifosfamide Day 1 through 5, ifosfamide
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/15/2017 7:43:52 AM Page 18 of 36
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

1000 mg/m2 IV Day 1 through 5; CISplatin 20 mg/m2 IV Day 1 through 5, CYCLE LENGTH: 21 days; COURSE: 2-4 cycles. NOTE:
mesna dose varies from reference.
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+10 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+10 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 – 7/27/2017 through 8/16/2017 (21 days), Planned
Day 1, Cycle 3 – Planned for 7/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular/Germ Cell Cancer (Advanced); THERAPY: PACLItaxel 175 mg/m2 IV Day 1, mesna 500 mg/m2 IV at start of
ifosfamide followed by mesna 500 mg/m2 IV or by mouth 4 and 8 hours after the start of ifosfamide Day 1 through 5, ifosfamide
1000 mg/m2 IV Day 1 through 5; CISplatin 20 mg/m2 IV Day 1 through 5, CYCLE LENGTH: 21 days; COURSE: 2-4 cycles. NOTE:
mesna dose varies from reference.
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+17 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+17 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+17 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+17 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+17 Approximate, Expires-S+365, Routine
AFP, TUMOR MARKER, SERUM
Expected-S+17 Approximate, Expires-S+365, Normal, Routine
HCG, QUANTITATIVE
Expected-S+17 Approximate, Expires-S+365, Routine
LD, TOTAL
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/15/2017 7:43:52 AM Page 19 of 36
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Expected-S+17 Approximate, Expires-S+365, Routine
URINALYSIS, NO MICROSCOPY
Expected-S+17 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, Urine Heme.
Monitoring Parameters (1)
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL or Urine
Hemoglobin greater than Trace or Creatinine greater than upper limits of normal.
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. See Emergency Medications.
** Rush dextrose primed line with 18 mL 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
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
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
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Give 30 minutes prior to treatment.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Give 30 minutes prior to treatment
palonosetron (ALOXI) injection 0.25 mg
0.25 mg, Intravenous, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/15/2017 7:43:52 AM Page 20 of 36
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

150 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
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) 343 mg in dextrose 5 % 500 mL non-PVC bag
343 mg (175 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 180 minutes. Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications. Use non-PVC tubing and 0.2 or 0.22 micron in-line filter during administration.
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, ONCE, 1 dose Starting when released
Give prior to start of ifosfamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
ifosfamide (IFEX) 1,960 mg in sodium chloride 0.9 % 500 mL bag
1,960 mg (1,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
CISplatin (PLATINOL) 39 mg in sodium chloride 0.9 % 1,000 mL bag
39 mg (rounded from 39.2 mg = 20 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60 minutes.
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Take Home Medications
mesna (MESNEX) 400 MG tab
Take 2.5 tabs by mouth 2 times daily. Take 4 & 8 hours after start of ifosfamide Day 1 thru 5., 1,000 mg (rounded from 980 mg =
500 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
Follow-Up
DAY 2 FOLLOW-UP
LABS: Urinalysis without microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide, mesna, CISplatin for 200 minutes.
DAY 3 FOLLOW-UP
LABS: Urinalysis without microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide, mesna, CISplatin for 200 minutes.
DAY 4 FOLLOW-UP
LABS: Creatinine, Phosphate, Magnesium, Potassium, Urinalysis without microscopy; CHEMOTHERAPY ROOM APPOINTMENT:
ifosfamide, mesna, CISplatin for 200 minutes.
DAY 5 FOLLOW-UP
LABS: Urinalysis without microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide, mesna, CISplatin for 200 minutes.
MULTIPLE DAY FOLLOW-UP (1)
DAY 8 AND 15 (if needed): LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/15/2017 7:43:52 AM Page 21 of 36
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Potassium,
Magnesium, Creatinine, Urinalysis without microscopy, Alpha-Fetoprotein, Quantitative HCG, Total LD; CHEMOTHERAPY ROOM
APPOINTMENT: PACLItaxel, ifosfamide, mesna, CISplatin for 300 minutes.
Day 2, Cycle 3 – Planned for 7/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular/Germ Cell Cancer (Advanced); THERAPY: PACLItaxel 175 mg/m2 IV Day 1, mesna 500 mg/m2 IV at start of
ifosfamide followed by mesna 500 mg/m2 IV or by mouth 4 and 8 hours after the start of ifosfamide Day 1 through 5, ifosfamide
1000 mg/m2 IV Day 1 through 5; CISplatin 20 mg/m2 IV Day 1 through 5, CYCLE LENGTH: 21 days; COURSE: 2-4 cycles. NOTE:
mesna dose varies from reference.
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
URINALYSIS, NO MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: Urine Heme.
Treatment Parameters
Hold and notify authorizing prescriber for Urine Hemoglobin greater than Trace.
Nursing Procedure, Assessment and Monitoring
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
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
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
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, ONCE, 1 dose Starting when released
Give prior to start of ifosfamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
ifosfamide (IFEX) 1,960 mg in sodium chloride 0.9 % 500 mL bag
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/15/2017 7:43:52 AM Page 22 of 36
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

1,960 mg (1,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
CISplatin (PLATINOL) 39 mg in sodium chloride 0.9 % 1,000 mL bag
39 mg (rounded from 39.2 mg = 20 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60 minutes.
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 3 – Planned for 7/29/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular/Germ Cell Cancer (Advanced); THERAPY: PACLItaxel 175 mg/m2 IV Day 1, mesna 500 mg/m2 IV at start of
ifosfamide followed by mesna 500 mg/m2 IV or by mouth 4 and 8 hours after the start of ifosfamide Day 1 through 5, ifosfamide
1000 mg/m2 IV Day 1 through 5; CISplatin 20 mg/m2 IV Day 1 through 5, CYCLE LENGTH: 21 days; COURSE: 2-4 cycles. NOTE:
mesna dose varies from reference.
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
URINALYSIS, NO MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: Urine Heme.
Treatment Parameters
Hold and notify authorizing prescriber for Urine Hemoglobin greater than Trace.
Nursing Procedure, Assessment and Monitoring
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/15/2017 7:43:52 AM Page 23 of 36
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
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, ONCE, 1 dose Starting when released
Give prior to start of ifosfamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
ifosfamide (IFEX) 1,960 mg in sodium chloride 0.9 % 500 mL bag
1,960 mg (1,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
CISplatin (PLATINOL) 39 mg in sodium chloride 0.9 % 1,000 mL bag
39 mg (rounded from 39.2 mg = 20 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60 minutes.
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 4, Cycle 3 – Planned for 7/30/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular/Germ Cell Cancer (Advanced); THERAPY: PACLItaxel 175 mg/m2 IV Day 1, mesna 500 mg/m2 IV at start of
ifosfamide followed by mesna 500 mg/m2 IV or by mouth 4 and 8 hours after the start of ifosfamide Day 1 through 5, ifosfamide
1000 mg/m2 IV Day 1 through 5; CISplatin 20 mg/m2 IV Day 1 through 5, CYCLE LENGTH: 21 days; COURSE: 2-4 cycles. NOTE:
mesna dose varies from reference.
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
CREATININE
Expected-S+1 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+1 Approximate, Expires-S+365, Normal, Routine
MAGNESIUM
Expected-S+1 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+1 Approximate, Expires-S+365, Routine
URINALYSIS, NO MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: Urine Heme.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/15/2017 7:43:52 AM Page 24 of 36
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Parameters
Hold and notify authorizing prescriber for Urine Hemoglobin greater than Trace.
Nursing Procedure, Assessment and Monitoring
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
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
palonosetron (ALOXI) injection 0.25 mg
0.25 mg, Intravenous, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
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, ONCE, 1 dose Starting when released
Give prior to start of ifosfamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
ifosfamide (IFEX) 1,960 mg in sodium chloride 0.9 % 500 mL bag
1,960 mg (1,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
CISplatin (PLATINOL) 39 mg in sodium chloride 0.9 % 1,000 mL bag
39 mg (rounded from 39.2 mg = 20 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60 minutes.
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 3 – Planned for 7/31/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular/Germ Cell Cancer (Advanced); THERAPY: PACLItaxel 175 mg/m2 IV Day 1, mesna 500 mg/m2 IV at start of
ifosfamide followed by mesna 500 mg/m2 IV or by mouth 4 and 8 hours after the start of ifosfamide Day 1 through 5, ifosfamide
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/15/2017 7:43:52 AM Page 25 of 36
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

1000 mg/m2 IV Day 1 through 5; CISplatin 20 mg/m2 IV Day 1 through 5, CYCLE LENGTH: 21 days; COURSE: 2-4 cycles. NOTE:
mesna dose varies from reference.
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
URINALYSIS, NO MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: Urine Heme.
Treatment Parameters
Hold and notify authorizing prescriber for Urine Hemoglobin greater than Trace.
Nursing Procedure, Assessment and Monitoring
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
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
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
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, ONCE, 1 dose Starting when released
Give prior to start of ifosfamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
ifosfamide (IFEX) 1,960 mg in sodium chloride 0.9 % 500 mL bag
1,960 mg (1,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
CISplatin (PLATINOL) 39 mg in sodium chloride 0.9 % 1,000 mL bag
39 mg (rounded from 39.2 mg = 20 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60 minutes.
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/15/2017 7:43:52 AM Page 26 of 36
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 8, Cycle 3 – Planned for 8/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular/Germ Cell Cancer (Advanced); THERAPY: PACLItaxel 175 mg/m2 IV Day 1, mesna 500 mg/m2 IV at start of
ifosfamide followed by mesna 500 mg/m2 IV or by mouth 4 and 8 hours after the start of ifosfamide Day 1 through 5, ifosfamide
1000 mg/m2 IV Day 1 through 5; CISplatin 20 mg/m2 IV Day 1 through 5, CYCLE LENGTH: 21 days; COURSE: 2-4 cycles. NOTE:
mesna dose varies from reference.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+3 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+3 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 3 – Planned for 8/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular/Germ Cell Cancer (Advanced); THERAPY: PACLItaxel 175 mg/m2 IV Day 1, mesna 500 mg/m2 IV at start of
ifosfamide followed by mesna 500 mg/m2 IV or by mouth 4 and 8 hours after the start of ifosfamide Day 1 through 5, ifosfamide
1000 mg/m2 IV Day 1 through 5; CISplatin 20 mg/m2 IV Day 1 through 5, CYCLE LENGTH: 21 days; COURSE: 2-4 cycles. NOTE:
mesna dose varies from reference.
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+10 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+10 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 – 8/17/2017 through 9/6/2017 (21 days), Planned
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/15/2017 7:43:52 AM Page 27 of 36
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Day 1, Cycle 4 – Planned for 8/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular/Germ Cell Cancer (Advanced); THERAPY: PACLItaxel 175 mg/m2 IV Day 1, mesna 500 mg/m2 IV at start of
ifosfamide followed by mesna 500 mg/m2 IV or by mouth 4 and 8 hours after the start of ifosfamide Day 1 through 5, ifosfamide
1000 mg/m2 IV Day 1 through 5; CISplatin 20 mg/m2 IV Day 1 through 5, CYCLE LENGTH: 21 days; COURSE: 2-4 cycles. NOTE:
mesna dose varies from reference.
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+17 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+17 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+17 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+17 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+17 Approximate, Expires-S+365, Routine
AFP, TUMOR MARKER, SERUM
Expected-S+17 Approximate, Expires-S+365, Normal, Routine
HCG, QUANTITATIVE
Expected-S+17 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+17 Approximate, Expires-S+365, Routine
URINALYSIS, NO MICROSCOPY
Expected-S+17 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, Urine Heme.
Monitoring Parameters (1)
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL or Urine
Hemoglobin greater than Trace or Creatinine greater than upper limits of normal.
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. See Emergency Medications.
** Rush dextrose primed line with 18 mL 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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/15/2017 7:43:52 AM Page 28 of 36
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

** 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
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
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
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Give 30 minutes prior to treatment.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Give 30 minutes prior to treatment
palonosetron (ALOXI) injection 0.25 mg
0.25 mg, Intravenous, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
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
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) 343 mg in dextrose 5 % 500 mL non-PVC bag
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/15/2017 7:43:52 AM Page 29 of 36
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

343 mg (175 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 180 minutes. Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications. Use non-PVC tubing and 0.2 or 0.22 micron in-line filter during administration.
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, ONCE, 1 dose Starting when released
Give prior to start of ifosfamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
ifosfamide (IFEX) 1,960 mg in sodium chloride 0.9 % 500 mL bag
1,960 mg (1,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
CISplatin (PLATINOL) 39 mg in sodium chloride 0.9 % 1,000 mL bag
39 mg (rounded from 39.2 mg = 20 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60 minutes.
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Take Home Medications
mesna (MESNEX) 400 MG tab
Take 2.5 tabs by mouth 2 times daily. Take 4 & 8 hours after start of ifosfamide Day 1 thru 5., 1,000 mg (rounded from 980 mg =
500 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
Follow-Up
DAY 2 FOLLOW-UP
LABS: Urinalysis without microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide, mesna, CISplatin for 200 minutes.
DAY 3 FOLLOW-UP
LABS: Urinalysis without microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide, mesna, CISplatin for 200 minutes.
DAY 4 FOLLOW-UP
LABS: Creatinine, Phosphate, Magnesium, Potassium, Urinalysis without microscopy; CHEMOTHERAPY ROOM APPOINTMENT:
ifosfamide, mesna, CISplatin for 200 minutes.
DAY 5 FOLLOW-UP
LABS: Urinalysis without microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide, mesna, CISplatin for 200 minutes.
MULTIPLE DAY FOLLOW-UP (1)
DAY 8 AND 15 (if needed): LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider.
Day 2, Cycle 4 – Planned for 8/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular/Germ Cell Cancer (Advanced); THERAPY: PACLItaxel 175 mg/m2 IV Day 1, mesna 500 mg/m2 IV at start of
ifosfamide followed by mesna 500 mg/m2 IV or by mouth 4 and 8 hours after the start of ifosfamide Day 1 through 5, ifosfamide
1000 mg/m2 IV Day 1 through 5; CISplatin 20 mg/m2 IV Day 1 through 5, CYCLE LENGTH: 21 days; COURSE: 2-4 cycles. NOTE:
mesna dose varies from reference.
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
URINALYSIS, NO MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/15/2017 7:43:52 AM Page 30 of 36
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Verify Labs
Verify pretreatment labs have been obtained and resulted: Urine Heme.
Treatment Parameters
Hold and notify authorizing prescriber for Urine Hemoglobin greater than Trace.
Nursing Procedure, Assessment and Monitoring
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
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
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
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, ONCE, 1 dose Starting when released
Give prior to start of ifosfamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
ifosfamide (IFEX) 1,960 mg in sodium chloride 0.9 % 500 mL bag
1,960 mg (1,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
CISplatin (PLATINOL) 39 mg in sodium chloride 0.9 % 1,000 mL bag
39 mg (rounded from 39.2 mg = 20 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60 minutes.
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 4 – Planned for 8/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular/Germ Cell Cancer (Advanced); THERAPY: PACLItaxel 175 mg/m2 IV Day 1, mesna 500 mg/m2 IV at start of
ifosfamide followed by mesna 500 mg/m2 IV or by mouth 4 and 8 hours after the start of ifosfamide Day 1 through 5, ifosfamide
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/15/2017 7:43:52 AM Page 31 of 36
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

1000 mg/m2 IV Day 1 through 5; CISplatin 20 mg/m2 IV Day 1 through 5, CYCLE LENGTH: 21 days; COURSE: 2-4 cycles. NOTE:
mesna dose varies from reference.
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
URINALYSIS, NO MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: Urine Heme.
Treatment Parameters
Hold and notify authorizing prescriber for Urine Hemoglobin greater than Trace.
Nursing Procedure, Assessment and Monitoring
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
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
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
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, ONCE, 1 dose Starting when released
Give prior to start of ifosfamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
ifosfamide (IFEX) 1,960 mg in sodium chloride 0.9 % 500 mL bag
1,960 mg (1,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
CISplatin (PLATINOL) 39 mg in sodium chloride 0.9 % 1,000 mL bag
39 mg (rounded from 39.2 mg = 20 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60 minutes.
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/15/2017 7:43:52 AM Page 32 of 36
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 4, Cycle 4 – Planned for 8/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular/Germ Cell Cancer (Advanced); THERAPY: PACLItaxel 175 mg/m2 IV Day 1, mesna 500 mg/m2 IV at start of
ifosfamide followed by mesna 500 mg/m2 IV or by mouth 4 and 8 hours after the start of ifosfamide Day 1 through 5, ifosfamide
1000 mg/m2 IV Day 1 through 5; CISplatin 20 mg/m2 IV Day 1 through 5, CYCLE LENGTH: 21 days; COURSE: 2-4 cycles. NOTE:
mesna dose varies from reference.
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
CREATININE
Expected-S+1 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+1 Approximate, Expires-S+365, Normal, Routine
MAGNESIUM
Expected-S+1 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+1 Approximate, Expires-S+365, Routine
URINALYSIS, NO MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: Urine Heme.
Treatment Parameters
Hold and notify authorizing prescriber for Urine Hemoglobin greater than Trace.
Nursing Procedure, Assessment and Monitoring
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/15/2017 7:43:52 AM Page 33 of 36
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
palonosetron (ALOXI) injection 0.25 mg
0.25 mg, Intravenous, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
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, ONCE, 1 dose Starting when released
Give prior to start of ifosfamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
ifosfamide (IFEX) 1,960 mg in sodium chloride 0.9 % 500 mL bag
1,960 mg (1,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
CISplatin (PLATINOL) 39 mg in sodium chloride 0.9 % 1,000 mL bag
39 mg (rounded from 39.2 mg = 20 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60 minutes.
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 4 – Planned for 8/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular/Germ Cell Cancer (Advanced); THERAPY: PACLItaxel 175 mg/m2 IV Day 1, mesna 500 mg/m2 IV at start of
ifosfamide followed by mesna 500 mg/m2 IV or by mouth 4 and 8 hours after the start of ifosfamide Day 1 through 5, ifosfamide
1000 mg/m2 IV Day 1 through 5; CISplatin 20 mg/m2 IV Day 1 through 5, CYCLE LENGTH: 21 days; COURSE: 2-4 cycles. NOTE:
mesna dose varies from reference.
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
URINALYSIS, NO MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: Urine Heme.
Treatment Parameters
Hold and notify authorizing prescriber for Urine Hemoglobin greater than Trace.
Nursing Procedure, Assessment and Monitoring
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/15/2017 7:43:52 AM Page 34 of 36
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 when released Until Specified
Monitor urine output and IV intake.
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
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
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, ONCE, 1 dose Starting when released
Give prior to start of ifosfamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
ifosfamide (IFEX) 1,960 mg in sodium chloride 0.9 % 500 mL bag
1,960 mg (1,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
CISplatin (PLATINOL) 39 mg in sodium chloride 0.9 % 1,000 mL bag
39 mg (rounded from 39.2 mg = 20 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60 minutes.
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 8, Cycle 4 – Planned for 8/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular/Germ Cell Cancer (Advanced); THERAPY: PACLItaxel 175 mg/m2 IV Day 1, mesna 500 mg/m2 IV at start of
ifosfamide followed by mesna 500 mg/m2 IV or by mouth 4 and 8 hours after the start of ifosfamide Day 1 through 5, ifosfamide
1000 mg/m2 IV Day 1 through 5; CISplatin 20 mg/m2 IV Day 1 through 5, CYCLE LENGTH: 21 days; COURSE: 2-4 cycles. NOTE:
mesna dose varies from reference.
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.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/15/2017 7:43:52 AM Page 35 of 36
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+3 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+3 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 4 – Planned for 8/31/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular/Germ Cell Cancer (Advanced); THERAPY: PACLItaxel 175 mg/m2 IV Day 1, mesna 500 mg/m2 IV at start of
ifosfamide followed by mesna 500 mg/m2 IV or by mouth 4 and 8 hours after the start of ifosfamide Day 1 through 5, ifosfamide
1000 mg/m2 IV Day 1 through 5; CISplatin 20 mg/m2 IV Day 1 through 5, CYCLE LENGTH: 21 days; COURSE: 2-4 cycles. NOTE:
mesna dose varies from reference.
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+10 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+10 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/15/2017 7:43:52 AM Page 36 of 36
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org