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CSC GU VeIP Cisplatin(21D:1-5) Ifosfamide(21D:1-5) Vinblastine(21D:1,2) VER 12-1-16 (HL 842)

CSC GU VeIP Cisplatin(21D:1-5) Ifosfamide(21D:1-5) Vinblastine(21D:1,2) VER 12-1-16 (HL 842) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GU


CSC GU VeIP CISPLATIN(21D1-5)IFOSFAMIDE(21D1-5)VINBLASTINE(21D1,2) VER 12-1-16 (HL 842) – 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: mesna 1200 mg/m2 IV Day 1 through 5 (given as 400 mg/m2 IV
prior to the start of ifosfamide and 4 and 8 hours after the start of ifosfamide), ifosfamide 1200 mg/m2 IV Day 1 through 5, CISplatin
20 mg/m2 IV Day 1 through 5, vinBLAStine 0.11 mg/kg IV Days 1 and 2; CYCLE LENGTH: 21 days; COURSE: 4 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
URINALYSIS, NO MICROSCOPY
Expected-S Approximate, Expires-S+365, Normal, 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
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
Take 2 tabs by mouth one time daily. Take on Day 6, 7 and 8., 8 mg, Disp-24 tab, R-1, 1 X DAILY starting S, Local Printer
prochlorperazine (COMPAZINE) 10 MG tab
Take 1 tab by mouth every 6 hours as needed for nausea/vomiting., 10 mg, Disp-30 tab, R-5, EVERY 6 HOURS PRN starting S,
Local Printer
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.
Cycle 1 – 6/15/2017 through 7/5/2017 (21 days), Planned
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Zztestonc,Jeff J [2507481]
6/15/2017 7:45:15 AM Page 1 of 32
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Day 1, Cycle 1 – Planned for 6/15/2017
Treatment Plan Information
Reference Information (1)
TESTICULAR, GERM CELL CANCER: Loehrer PJ, et al. J Clin Oncol 1998;16:2500-4.
Reference Information (2)
TESTICULAR/GERM CELL CANCER: Motzer RJ, et al. Cancer 1991;67:1305-10.
Treatment Plan Summary
DISEASE: Testicular, Germ Cell Cancer (Advanced); THERAPY: mesna 1200 mg/m2 IV Day 1 through 5 (given as 400 mg/m2 IV
prior to the start of ifosfamide and 4 and 8 hours after the start of ifosfamide), ifosfamide 1200 mg/m2 IV Day 1 through 5, CISplatin
20 mg/m2 IV Day 1 through 5, vinBLAStine 0.11 mg/kg IV Days 1 and 2; CYCLE LENGTH: 21 days; COURSE: 4 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
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, Magnesium, 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.
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
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Zztestonc,Jeff J [2507481]
6/15/2017 7:45:15 AM Page 2 of 32
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 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.
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) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
mesna (MESNEX) 784 mg in sodium chloride 0.9 % 50 mL bag
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide or cyclophosphamide.
ifosfamide (IFEX) 2,350 mg in sodium chloride 0.9 % 250 mL bag
2,350 mg (rounded from 2,352 mg = 1,200 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.
vinBLAStine (VELBAN) 8.8 mg in sodium chloride 0.9 % 25 mL bag
8.8 mg (0.11 mg/kg × 80 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
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 tabs by mouth 2 times daily. Take 4 & 8 hours after start of ifosfamide Day 1 thru 5, 800 mg (rounded from 784 mg = 400
mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-5, 2 X DAILY starting S
MD may delete this order and order IV mesna.
Follow-Up
DAY 2 FOLLOW-UP
LABS: Urinalysis without microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide, mesna, CISplatin and vinBLAStine for
300 minutes.
DAY 3 FOLLOW-UP
LABS: Urinalysis without microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide, mesna, CISplatin for 300 minutes.
DAY 4 FOLLOW-UP
LABS: Magnesium, Potassium, Creatinine, Phosphate, Urinalysis without microscopy; CHEMOTHERAPY ROOM APPOINTMENT:
ifosfamide, mesna, CISplatin for 300 minutes.
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Zztestonc,Jeff J [2507481]
6/15/2017 7:45:15 AM Page 3 of 32
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

DAY 5 FOLLOW-UP
LABS: Urinalysis without microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide, mesna, CISplatin for 300 minutes.
MULTIPLE DAY FOLLOW-UP (1)
DAY 8 AND 15 (if needed): LABS: Alpha-Fetoprotein, Quantitative HCG, Total LD.
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Magnesium,
Potassium, Creatinine, Urinalysis without microscopy, Alpha-Fetoprotein, Quantitative HCG, Total LD; CHEMOTHERAPY ROOM
APPOINTMENT: ifosfamide, mesna, CISplatin and vinBLAStine 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: mesna 1200 mg/m2 IV Day 1 through 5 (given as 400 mg/m2 IV
prior to the start of ifosfamide and 4 and 8 hours after the start of ifosfamide), ifosfamide 1200 mg/m2 IV Day 1 through 5, CISplatin
20 mg/m2 IV Day 1 through 5, vinBLAStine 0.11 mg/kg IV Days 1 and 2; CYCLE LENGTH: 21 days; COURSE: 4 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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
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Zztestonc,Jeff J [2507481]
6/15/2017 7:45:15 AM Page 4 of 32
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
mesna (MESNEX) 784 mg in sodium chloride 0.9 % 50 mL bag
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide or cyclophosphamide.
ifosfamide (IFEX) 2,350 mg in sodium chloride 0.9 % 250 mL bag
2,350 mg (rounded from 2,352 mg = 1,200 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.
vinBLAStine (VELBAN) 8.8 mg in sodium chloride 0.9 % 25 mL bag
8.8 mg (0.11 mg/kg × 80 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
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
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular, Germ Cell Cancer (Advanced); THERAPY: mesna 1200 mg/m2 IV Day 1 through 5 (given as 400 mg/m2 IV
prior to the start of ifosfamide and 4 and 8 hours after the start of ifosfamide), ifosfamide 1200 mg/m2 IV Day 1 through 5, CISplatin
20 mg/m2 IV Day 1 through 5, vinBLAStine 0.11 mg/kg IV Days 1 and 2; CYCLE LENGTH: 21 days; COURSE: 4 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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
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Zztestonc,Jeff J [2507481]
6/15/2017 7:45:15 AM Page 5 of 32
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 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) 784 mg in sodium chloride 0.9 % 50 mL bag
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide or cyclophosphamide.
ifosfamide (IFEX) 2,350 mg in sodium chloride 0.9 % 250 mL bag
2,350 mg (rounded from 2,352 mg = 1,200 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 1 – Planned for 6/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular, Germ Cell Cancer (Advanced); THERAPY: mesna 1200 mg/m2 IV Day 1 through 5 (given as 400 mg/m2 IV
prior to the start of ifosfamide and 4 and 8 hours after the start of ifosfamide), ifosfamide 1200 mg/m2 IV Day 1 through 5, CISplatin
20 mg/m2 IV Day 1 through 5, vinBLAStine 0.11 mg/kg IV Days 1 and 2; CYCLE LENGTH: 21 days; COURSE: 4 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
MAGNESIUM
Expected-S+1 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+1 Approximate, Expires-S+365, Routine
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Zztestonc,Jeff J [2507481]
6/15/2017 7:45:15 AM Page 6 of 32
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

CREATININE
Expected-S+1 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+1 Approximate, Expires-S+365, Normal, 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) 784 mg in sodium chloride 0.9 % 50 mL bag
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide or cyclophosphamide.
ifosfamide (IFEX) 2,350 mg in sodium chloride 0.9 % 250 mL bag
2,350 mg (rounded from 2,352 mg = 1,200 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
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Zztestonc,Jeff J [2507481]
6/15/2017 7:45:15 AM Page 7 of 32
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 5, Cycle 1 – Planned for 6/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular, Germ Cell Cancer (Advanced); THERAPY: mesna 1200 mg/m2 IV Day 1 through 5 (given as 400 mg/m2 IV
prior to the start of ifosfamide and 4 and 8 hours after the start of ifosfamide), ifosfamide 1200 mg/m2 IV Day 1 through 5, CISplatin
20 mg/m2 IV Day 1 through 5, vinBLAStine 0.11 mg/kg IV Days 1 and 2; CYCLE LENGTH: 21 days; COURSE: 4 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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) 784 mg in sodium chloride 0.9 % 50 mL bag
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Zztestonc,Jeff J [2507481]
6/15/2017 7:45:15 AM Page 8 of 32
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide or cyclophosphamide.
ifosfamide (IFEX) 2,350 mg in sodium chloride 0.9 % 250 mL bag
2,350 mg (rounded from 2,352 mg = 1,200 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 10, Cycle 1 – Planned for 6/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular, Germ Cell Cancer (Advanced); THERAPY: mesna 1200 mg/m2 IV Day 1 through 5 (given as 400 mg/m2 IV
prior to the start of ifosfamide and 4 and 8 hours after the start of ifosfamide), ifosfamide 1200 mg/m2 IV Day 1 through 5, CISplatin
20 mg/m2 IV Day 1 through 5, vinBLAStine 0.11 mg/kg IV Days 1 and 2; CYCLE LENGTH: 21 days; COURSE: 4 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+5 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+5 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: mesna 1200 mg/m2 IV Day 1 through 5 (given as 400 mg/m2 IV
prior to the start of ifosfamide and 4 and 8 hours after the start of ifosfamide), ifosfamide 1200 mg/m2 IV Day 1 through 5, CISplatin
20 mg/m2 IV Day 1 through 5, vinBLAStine 0.11 mg/kg IV Days 1 and 2; CYCLE LENGTH: 21 days; COURSE: 4 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Jeff J [2507481]
6/15/2017 7:45:15 AM Page 9 of 32
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
MAGNESIUM
Expected-S+17 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+17 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+17 Approximate, Expires-S+365, Routine
URINALYSIS, NO MICROSCOPY
Expected-S+17 Approximate, Expires-S+365, Normal, 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
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, Magnesium, 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.
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
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Zztestonc,Jeff J [2507481]
6/15/2017 7:45:15 AM Page 10 of 32
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
mesna (MESNEX) 784 mg in sodium chloride 0.9 % 50 mL bag
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide or cyclophosphamide.
ifosfamide (IFEX) 2,350 mg in sodium chloride 0.9 % 250 mL bag
2,350 mg (rounded from 2,352 mg = 1,200 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.
vinBLAStine (VELBAN) 8.8 mg in sodium chloride 0.9 % 25 mL bag
8.8 mg (0.11 mg/kg × 80 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
DAY 2 FOLLOW-UP
LABS: Urinalysis without microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide, mesna, CISplatin and vinBLAStine for
300 minutes.
DAY 3 FOLLOW-UP
LABS: Urinalysis without microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide, mesna, CISplatin for 300 minutes.
DAY 4 FOLLOW-UP
LABS: Magnesium, Potassium, Creatinine, Phosphate, Urinalysis without microscopy; CHEMOTHERAPY ROOM APPOINTMENT:
ifosfamide, mesna, CISplatin for 300 minutes.
DAY 5 FOLLOW-UP
LABS: Urinalysis without microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide, mesna, CISplatin for 300 minutes.
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Magnesium,
Potassium, Creatinine, Urinalysis without microscopy, Alpha-Fetoprotein, Quantitative HCG, Total LD; CHEMOTHERAPY ROOM
APPOINTMENT: ifosfamide, mesna, CISplatin and vinBLAStine 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: mesna 1200 mg/m2 IV Day 1 through 5 (given as 400 mg/m2 IV
prior to the start of ifosfamide and 4 and 8 hours after the start of ifosfamide), ifosfamide 1200 mg/m2 IV Day 1 through 5, CISplatin
20 mg/m2 IV Day 1 through 5, vinBLAStine 0.11 mg/kg IV Days 1 and 2; CYCLE LENGTH: 21 days; COURSE: 4 cycles.
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Jeff J [2507481]
6/15/2017 7:45:15 AM Page 11 of 32
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
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) 784 mg in sodium chloride 0.9 % 50 mL bag
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide or cyclophosphamide.
ifosfamide (IFEX) 2,350 mg in sodium chloride 0.9 % 250 mL bag
2,350 mg (rounded from 2,352 mg = 1,200 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.
vinBLAStine (VELBAN) 8.8 mg in sodium chloride 0.9 % 25 mL bag
8.8 mg (0.11 mg/kg × 80 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
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.
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Zztestonc,Jeff J [2507481]
6/15/2017 7:45:15 AM Page 12 of 32
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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: mesna 1200 mg/m2 IV Day 1 through 5 (given as 400 mg/m2 IV
prior to the start of ifosfamide and 4 and 8 hours after the start of ifosfamide), ifosfamide 1200 mg/m2 IV Day 1 through 5, CISplatin
20 mg/m2 IV Day 1 through 5, vinBLAStine 0.11 mg/kg IV Days 1 and 2; CYCLE LENGTH: 21 days; COURSE: 4 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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) 784 mg in sodium chloride 0.9 % 50 mL bag
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide or cyclophosphamide.
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Zztestonc,Jeff J [2507481]
6/15/2017 7:45:15 AM Page 13 of 32
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

ifosfamide (IFEX) 2,350 mg in sodium chloride 0.9 % 250 mL bag
2,350 mg (rounded from 2,352 mg = 1,200 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: mesna 1200 mg/m2 IV Day 1 through 5 (given as 400 mg/m2 IV
prior to the start of ifosfamide and 4 and 8 hours after the start of ifosfamide), ifosfamide 1200 mg/m2 IV Day 1 through 5, CISplatin
20 mg/m2 IV Day 1 through 5, vinBLAStine 0.11 mg/kg IV Days 1 and 2; CYCLE LENGTH: 21 days; COURSE: 4 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
MAGNESIUM
Expected-S+1 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+1 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+1 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+1 Approximate, Expires-S+365, Normal, 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
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Zztestonc,Jeff J [2507481]
6/15/2017 7:45:15 AM Page 14 of 32
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 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) 784 mg in sodium chloride 0.9 % 50 mL bag
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide or cyclophosphamide.
ifosfamide (IFEX) 2,350 mg in sodium chloride 0.9 % 250 mL bag
2,350 mg (rounded from 2,352 mg = 1,200 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 2 – Planned for 7/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular, Germ Cell Cancer (Advanced); THERAPY: mesna 1200 mg/m2 IV Day 1 through 5 (given as 400 mg/m2 IV
prior to the start of ifosfamide and 4 and 8 hours after the start of ifosfamide), ifosfamide 1200 mg/m2 IV Day 1 through 5, CISplatin
20 mg/m2 IV Day 1 through 5, vinBLAStine 0.11 mg/kg IV Days 1 and 2; CYCLE LENGTH: 21 days; COURSE: 4 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
URINALYSIS, NO MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Normal, Routine
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Zztestonc,Jeff J [2507481]
6/15/2017 7:45:15 AM Page 15 of 32
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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) 784 mg in sodium chloride 0.9 % 50 mL bag
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide or cyclophosphamide.
ifosfamide (IFEX) 2,350 mg in sodium chloride 0.9 % 250 mL bag
2,350 mg (rounded from 2,352 mg = 1,200 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 10, Cycle 2 – Planned for 7/15/2017
Treatment Plan Information
Treatment Plan Summary
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Zztestonc,Jeff J [2507481]
6/15/2017 7:45:15 AM Page 16 of 32
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

DISEASE: Testicular, Germ Cell Cancer (Advanced); THERAPY: mesna 1200 mg/m2 IV Day 1 through 5 (given as 400 mg/m2 IV
prior to the start of ifosfamide and 4 and 8 hours after the start of ifosfamide), ifosfamide 1200 mg/m2 IV Day 1 through 5, CISplatin
20 mg/m2 IV Day 1 through 5, vinBLAStine 0.11 mg/kg IV Days 1 and 2; CYCLE LENGTH: 21 days; COURSE: 4 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+5 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+5 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: mesna 1200 mg/m2 IV Day 1 through 5 (given as 400 mg/m2 IV
prior to the start of ifosfamide and 4 and 8 hours after the start of ifosfamide), ifosfamide 1200 mg/m2 IV Day 1 through 5, CISplatin
20 mg/m2 IV Day 1 through 5, vinBLAStine 0.11 mg/kg IV Days 1 and 2; CYCLE LENGTH: 21 days; COURSE: 4 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+17 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+17 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+17 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+17 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+17 Approximate, Expires-S+365, Routine
URINALYSIS, NO MICROSCOPY
Expected-S+17 Approximate, Expires-S+365, Normal, Routine
AFP, TUMOR MARKER, SERUM
Expected-S+17 Approximate, Expires-S+365, Normal, Routine
HCG, QUANTITATIVE
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Zztestonc,Jeff J [2507481]
6/15/2017 7:45:15 AM Page 17 of 32
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
LD, TOTAL
Expected-S+17 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, Magnesium, 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.
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.
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) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
mesna (MESNEX) 784 mg in sodium chloride 0.9 % 50 mL bag
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide or cyclophosphamide.
ifosfamide (IFEX) 2,350 mg in sodium chloride 0.9 % 250 mL bag
2,350 mg (rounded from 2,352 mg = 1,200 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.
vinBLAStine (VELBAN) 8.8 mg in sodium chloride 0.9 % 25 mL bag
8.8 mg (0.11 mg/kg × 80 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Conditional Orders
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Zztestonc,Jeff J [2507481]
6/15/2017 7:45:15 AM Page 18 of 32
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
DAY 2 FOLLOW-UP
LABS: Urinalysis without microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide, mesna, CISplatin and vinBLAStine for
300 minutes.
DAY 3 FOLLOW-UP
LABS: Urinalysis without microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide, mesna, CISplatin for 300 minutes.
DAY 4 FOLLOW-UP
LABS: Magnesium, Potassium, Creatinine, Phosphate, Urinalysis without microscopy; CHEMOTHERAPY ROOM APPOINTMENT:
ifosfamide, mesna, CISplatin for 300 minutes.
DAY 5 FOLLOW-UP
LABS: Urinalysis without microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide, mesna, CISplatin for 300 minutes.
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Magnesium,
Potassium, Creatinine, Urinalysis without microscopy, Alpha-Fetoprotein, Quantitative HCG, Total LD; CHEMOTHERAPY ROOM
APPOINTMENT: ifosfamide, mesna, CISplatin and vinBLAStine 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: mesna 1200 mg/m2 IV Day 1 through 5 (given as 400 mg/m2 IV
prior to the start of ifosfamide and 4 and 8 hours after the start of ifosfamide), ifosfamide 1200 mg/m2 IV Day 1 through 5, CISplatin
20 mg/m2 IV Day 1 through 5, vinBLAStine 0.11 mg/kg IV Days 1 and 2; CYCLE LENGTH: 21 days; COURSE: 4 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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
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Zztestonc,Jeff J [2507481]
6/15/2017 7:45:15 AM Page 19 of 32
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
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
mesna (MESNEX) 784 mg in sodium chloride 0.9 % 50 mL bag
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide or cyclophosphamide.
ifosfamide (IFEX) 2,350 mg in sodium chloride 0.9 % 250 mL bag
2,350 mg (rounded from 2,352 mg = 1,200 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.
vinBLAStine (VELBAN) 8.8 mg in sodium chloride 0.9 % 25 mL bag
8.8 mg (0.11 mg/kg × 80 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
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: mesna 1200 mg/m2 IV Day 1 through 5 (given as 400 mg/m2 IV
prior to the start of ifosfamide and 4 and 8 hours after the start of ifosfamide), ifosfamide 1200 mg/m2 IV Day 1 through 5, CISplatin
20 mg/m2 IV Day 1 through 5, vinBLAStine 0.11 mg/kg IV Days 1 and 2; CYCLE LENGTH: 21 days; COURSE: 4 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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.
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Zztestonc,Jeff J [2507481]
6/15/2017 7:45:15 AM Page 20 of 32
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
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
mesna (MESNEX) 784 mg in sodium chloride 0.9 % 50 mL bag
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide or cyclophosphamide.
ifosfamide (IFEX) 2,350 mg in sodium chloride 0.9 % 250 mL bag
2,350 mg (rounded from 2,352 mg = 1,200 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: mesna 1200 mg/m2 IV Day 1 through 5 (given as 400 mg/m2 IV
prior to the start of ifosfamide and 4 and 8 hours after the start of ifosfamide), ifosfamide 1200 mg/m2 IV Day 1 through 5, CISplatin
20 mg/m2 IV Day 1 through 5, vinBLAStine 0.11 mg/kg IV Days 1 and 2; CYCLE LENGTH: 21 days; COURSE: 4 cycles.
IV Access
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Zztestonc,Jeff J [2507481]
6/15/2017 7:45:15 AM Page 21 of 32
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
MAGNESIUM
Expected-S+1 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+1 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+1 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+1 Approximate, Expires-S+365, Normal, 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) 784 mg in sodium chloride 0.9 % 50 mL bag
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide or cyclophosphamide.
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Zztestonc,Jeff J [2507481]
6/15/2017 7:45:15 AM Page 22 of 32
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

ifosfamide (IFEX) 2,350 mg in sodium chloride 0.9 % 250 mL bag
2,350 mg (rounded from 2,352 mg = 1,200 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: mesna 1200 mg/m2 IV Day 1 through 5 (given as 400 mg/m2 IV
prior to the start of ifosfamide and 4 and 8 hours after the start of ifosfamide), ifosfamide 1200 mg/m2 IV Day 1 through 5, CISplatin
20 mg/m2 IV Day 1 through 5, vinBLAStine 0.11 mg/kg IV Days 1 and 2; CYCLE LENGTH: 21 days; COURSE: 4 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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
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Zztestonc,Jeff J [2507481]
6/15/2017 7:45:15 AM Page 23 of 32
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
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
mesna (MESNEX) 784 mg in sodium chloride 0.9 % 50 mL bag
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide or cyclophosphamide.
ifosfamide (IFEX) 2,350 mg in sodium chloride 0.9 % 250 mL bag
2,350 mg (rounded from 2,352 mg = 1,200 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 10, Cycle 3 – Planned for 8/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular, Germ Cell Cancer (Advanced); THERAPY: mesna 1200 mg/m2 IV Day 1 through 5 (given as 400 mg/m2 IV
prior to the start of ifosfamide and 4 and 8 hours after the start of ifosfamide), ifosfamide 1200 mg/m2 IV Day 1 through 5, CISplatin
20 mg/m2 IV Day 1 through 5, vinBLAStine 0.11 mg/kg IV Days 1 and 2; CYCLE LENGTH: 21 days; COURSE: 4 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+5 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+5 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
Day 1, Cycle 4 – Planned for 8/17/2017
Treatment Plan Information
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Zztestonc,Jeff J [2507481]
6/15/2017 7:45:15 AM Page 24 of 32
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Testicular, Germ Cell Cancer (Advanced); THERAPY: mesna 1200 mg/m2 IV Day 1 through 5 (given as
400 mg/m2 IV prior to the start of ifosfamide and 4 and 8 hours after the start of ifosfamide), ifosfamide 1200 mg/m2
IV Day 1 through 5, CISplatin 20 mg/m2 IV Day 1 through 5, vinBLAStine 0.11 mg/kg IV Days 1 and 2; CYCLE
LENGTH: 21 days; COURSE: 4 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+17 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+17 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+17 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+17 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+17 Approximate, Expires-S+365, Routine
URINALYSIS, NO MICROSCOPY
Expected-S+17 Approximate, Expires-S+365, Normal, 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
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, Magnesium, 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.
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.
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Zztestonc,Jeff J [2507481]
6/15/2017 7:45:15 AM Page 25 of 32
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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.
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) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
mesna (MESNEX) 784 mg in sodium chloride 0.9 % 50 mL bag
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide or cyclophosphamide.
ifosfamide (IFEX) 2,350 mg in sodium chloride 0.9 % 250 mL bag
2,350 mg (rounded from 2,352 mg = 1,200 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.
vinBLAStine (VELBAN) 8.8 mg in sodium chloride 0.9 % 25 mL bag
8.8 mg (0.11 mg/kg × 80 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Follow-Up
DAY 2 FOLLOW-UP
LABS: Urinalysis without microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide, mesna, CISplatin and vinBLAStine for
300 minutes.
DAY 3 FOLLOW-UP
LABS: Urinalysis without microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide, mesna, CISplatin for 300 minutes.
DAY 4 FOLLOW-UP
LABS: Magnesium, Potassium, Creatinine, Phosphate, Urinalysis without microscopy; CHEMOTHERAPY ROOM APPOINTMENT:
ifosfamide, mesna, CISplatin for 300 minutes.
DAY 5 FOLLOW-UP
LABS: Urinalysis without microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide, mesna, CISplatin for 300 minutes.
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Magnesium, Potassium, Creatinine,
Urinalysis without microscopy, Alpha-Fetoprotein, Quantitative HCG, Total LD.
Day 2, Cycle 4 – Planned for 8/18/2017
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Zztestonc,Jeff J [2507481]
6/15/2017 7:45:15 AM Page 26 of 32
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: mesna 1200 mg/m2 IV Day 1 through 5 (given as 400 mg/m2 IV
prior to the start of ifosfamide and 4 and 8 hours after the start of ifosfamide), ifosfamide 1200 mg/m2 IV Day 1 through 5, CISplatin
20 mg/m2 IV Day 1 through 5, vinBLAStine 0.11 mg/kg IV Days 1 and 2; CYCLE LENGTH: 21 days; COURSE: 4 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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) 784 mg in sodium chloride 0.9 % 50 mL bag
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide or cyclophosphamide.
ifosfamide (IFEX) 2,350 mg in sodium chloride 0.9 % 250 mL bag
2,350 mg (rounded from 2,352 mg = 1,200 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.
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Zztestonc,Jeff J [2507481]
6/15/2017 7:45:15 AM Page 27 of 32
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

vinBLAStine (VELBAN) 8.8 mg in sodium chloride 0.9 % 25 mL bag
8.8 mg (0.11 mg/kg × 80 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
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: mesna 1200 mg/m2 IV Day 1 through 5 (given as 400 mg/m2 IV
prior to the start of ifosfamide and 4 and 8 hours after the start of ifosfamide), ifosfamide 1200 mg/m2 IV Day 1 through 5, CISplatin
20 mg/m2 IV Day 1 through 5, vinBLAStine 0.11 mg/kg IV Days 1 and 2; CYCLE LENGTH: 21 days; COURSE: 4 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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
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Zztestonc,Jeff J [2507481]
6/15/2017 7:45:15 AM Page 28 of 32
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
mesna (MESNEX) 784 mg in sodium chloride 0.9 % 50 mL bag
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide or cyclophosphamide.
ifosfamide (IFEX) 2,350 mg in sodium chloride 0.9 % 250 mL bag
2,350 mg (rounded from 2,352 mg = 1,200 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 4 – Planned for 8/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular, Germ Cell Cancer (Advanced); THERAPY: mesna 1200 mg/m2 IV Day 1 through 5 (given as 400 mg/m2 IV
prior to the start of ifosfamide and 4 and 8 hours after the start of ifosfamide), ifosfamide 1200 mg/m2 IV Day 1 through 5, CISplatin
20 mg/m2 IV Day 1 through 5, vinBLAStine 0.11 mg/kg IV Days 1 and 2; CYCLE LENGTH: 21 days; COURSE: 4 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
MAGNESIUM
Expected-S+1 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+1 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+1 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+1 Approximate, Expires-S+365, Normal, 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
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Zztestonc,Jeff J [2507481]
6/15/2017 7:45:15 AM Page 29 of 32
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
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) 784 mg in sodium chloride 0.9 % 50 mL bag
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide or cyclophosphamide.
ifosfamide (IFEX) 2,350 mg in sodium chloride 0.9 % 250 mL bag
2,350 mg (rounded from 2,352 mg = 1,200 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: mesna 1200 mg/m2 IV Day 1 through 5 (given as 400 mg/m2 IV
prior to the start of ifosfamide and 4 and 8 hours after the start of ifosfamide), ifosfamide 1200 mg/m2 IV Day 1 through 5, CISplatin
20 mg/m2 IV Day 1 through 5, vinBLAStine 0.11 mg/kg IV Days 1 and 2; CYCLE LENGTH: 21 days; COURSE: 4 cycles.
IV Access
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Zztestonc,Jeff J [2507481]
6/15/2017 7:45:15 AM Page 30 of 32
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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) 784 mg in sodium chloride 0.9 % 50 mL bag
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide or cyclophosphamide.
ifosfamide (IFEX) 2,350 mg in sodium chloride 0.9 % 250 mL bag
2,350 mg (rounded from 2,352 mg = 1,200 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.
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Zztestonc,Jeff J [2507481]
6/15/2017 7:45:15 AM Page 31 of 32
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 10, Cycle 4 – Planned for 8/26/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Testicular, Germ Cell Cancer (Advanced); THERAPY: mesna 1200 mg/m2 IV Day 1 through 5 (given as 400 mg/m2 IV
prior to the start of ifosfamide and 4 and 8 hours after the start of ifosfamide), ifosfamide 1200 mg/m2 IV Day 1 through 5, CISplatin
20 mg/m2 IV Day 1 through 5, vinBLAStine 0.11 mg/kg IV Days 1 and 2; CYCLE LENGTH: 21 days; COURSE: 4 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+5 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+5 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,Jeff J [2507481]
6/15/2017 7:45:15 AM Page 32 of 32
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org