/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-96727-en.cckm

201706166

page

100

UWHC,UWMF,

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

CSC GU-INPT CISplatin (21D2-5) Ifosfamide (21D2-5) PACLitaxel (21D1)

CSC GU-INPT CISplatin (21D2-5) Ifosfamide (21D2-5) PACLitaxel (21D1) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GU


Properties CSC GU-INPT CISPLATIN(21D:2-5)/IFOSFAMIDE(21D:2-5)/PACLITAXEL(21D:1) VER: 10-11-12 –
10/16/2012 through 11/5/2012 (21 days), Planned Cycle 1 –
Planned for 10/16/2012 Day 1, Cycle 1 –
Treatment Plan Information
Reference Information (1)
TESTICULAR CANCER: Kondagunta G, et al. J Clin Oncol. 2005; 23(27):6549-55
Treatment Plan Summary
DISEASE: Testicular Cancer (Advanced); THERAPY: PACLItaxel 250 mg/m2 IV continuous infusion over 24
hours Day 1, CISplatin 25 mg/m2 IV Day 2 through 5, mesna 500 mg/m2 IV prior to ifosfamide and 4 hours and 8
hours after start of ifosfamide Day 2 through 5, ifosfamide 1500 mg/m2 IV Day 2 through 5; CYCLE LENGTH: 21
days; COURSE: 4 cycles; NOTE: If patient is discharged early, order oral mesna (oral dose = 2 X IV dose) for
remaining doses
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
ONCE Starting S at 0000
ABSOLUTE NEUTROPHIL COUNT
ONCE Starting S at 0000
ELECTROLYTES
ONCE Starting S at 0000
BUN
ONCE Starting S at 0000
CREATININE
ONCE Starting S at 0000
MAGNESIUM
ONCE Starting S at 0000
BILIRUBIN, TOTAL
ONCE Starting S at 0000
AST/SGOT
ONCE Starting S at 0000
ALT/SGPT
ONCE Starting S at 0000
ALBUMIN
ONCE Starting S at 0000
URINALYSIS WITH MICROSCOPY
NEXT AM Starting S+1 at 0000 until S+5 for 5 occurrences
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
10/16/2012 10:23:32 AM Page 1 of 20
Copyright © 2012 University of Wisconsin Hospital and Clinics Authority



Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained on Day 1: ANC, Platelets, Creatinine, Total Bilirubin, AST, ALT,
Albumin
Verify Labs (2)
Verify pretreatment labs have been obtained on Day 2 through 5: Urinalysis
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL, Platelets less than 75K/µL, Creatinine
greater than 2 mg/dL or Creatinine Clearance less than 50 mL/min, Total Bilirubin greater than 2 mg/dL, AST or
ALT greater than 3 X ULN or Albumin less than 3 gm/dL.
Treatment Parameters (2)
Hold treatment and notify authorizing prescriber for Urine RBC greater than 2/hpf prior to ifosfamide
administration on Day 2 through 5.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if
patient has not taken medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a
location to optimize emergency care. ** Rush dextrose primed line with 18mL prior to programming start rate for
infusion. ** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone). ** For
first and second doses, titrate up to full infusion rate over a minimum of 15 minutes. ** RN to stay at patient’s
bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction during
first dose.
Vital Signs
SEE COMMENTS Starting S at 0000 Until Specified, PACLItaxel: Monitor vital signs every 15 minutes for the first
hour then every 30 minutes for the remainder of the infusion for the first and second dose. If previous doses
tolerated, monitor vital signs every 30 minutes for all subsequent doses.
Monitoring Parameters (1)
Monitor for ifosfamide-related neurotoxicity (somnolence, agitation, confusion, delirium, hallucinations,
incontinence, palsy, diplopia or aphasia). Stop infusion and contact physician if toxicity is suspected.
Monitoring Parameters (2)
Monitor and notify physician for signs and symptoms of hemorrhagic cystitis (dysuria).
Measure Intake And Output
EVERY 4 HOURS Starting S+1 at 0000 Until Specified, Measure IV intake and urine output.
Flush Venous Access Device per Guidelines
Order details
sodium chloride 0.9% flush 10 mL injection
Flush, PRN Starting S at 0000 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 S at 0000 Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 100 UNIT/ML injection 500 units
500 units, Flush, PRN Starting S at 0000 Until Discontinued, flush/line care
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
10/16/2012 10:23:32 AM Page 2 of 20
Copyright © 2012 University of Wisconsin Hospital and Clinics Authority


Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 100 mL/hr, Intravenous, CONTINUOUS Starting S at 0000 Until Discontinued
Pre-Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released
Give 30 minutes prior to PACLItaxel.
for 1 Minutes
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released
Give 30 minutes prior to PACLItaxel.
for 5 Minutes
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9% 250mL bag
150 mg, Intravenous, ONCE, 1 dose Starting S+1
Do not infuse with CA++, Mg++, Lactated Ringer's solutions
for 30 Minutes
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, EVERY 24 HOURS, 4 doses Starting S+1
Give prior to chemotherapy. May give IV if unable to tolerate PO.
ondansetron (ZOFRAN) 12 mg in sodium chloride 0.9 % 50 mL bag
12 mg, Intravenous, EVERY 24 HOURS PRN, 4 doses Starting S+1, nausea/vomiting
Give prior to chemotherapy if patient unable to tolerate PO.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, EVERY 24 HOURS, 4 doses Starting S+1
Give prior to chemotherapy. May give IV if unable to tolerate PO.
dexamethasone (DECADRON) injection 8 mg
8 mg, Intravenous, EVERY 24 HOURS PRN, For 5 days Starting S+1, nausea/vomiting
Give prior to chemotherapy if patient unable to tolerate PO.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
dexamethasone (DECADRON) injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
10/16/2012 10:23:32 AM Page 3 of 20
Copyright © 2012 University of Wisconsin Hospital and Clinics Authority


Treatment Medications
PACLItaxel (TAXOL) 518 mg in dextrose 5 % 500 mL non-PVC bag
250 mg/m2 × 2.07 m2 (Treatment plan actual BSA) = 518 mg, Intravenous, ONCE, 1 dose Starting when released

Hypersensitivity risk. See emergency medications. Infuse over 24 hours. Use non-PVC tubing and 0.22 micron in-
line filter during administration
CISplatin (PLATINOL) 52 mg in sodium chloride 0.9 % 1,000 mL bag
25 mg/m2 × 2.07 m2 (Treatment plan actual BSA) = 52 mg, Intravenous, EVERY 24 HOURS, 4 doses Starting
S+1
For 60-120 minutes.
mesna (MESNEX) 1,035 mg in sodium chloride 0.9 % 50 mL bag
500 mg/m2 × 2.07 m2 (Treatment plan actual BSA) = 1,035 mg, Intravenous, 3 X DAILY, 12 doses Starting S+1
at 0000
Give prior to ifosfamide and 4 hours and 8 hours after start of ifosfamide infusion on Day 2 through 5. If patient
discharged prior to completing all IV mesna doses, remaining doses must be given orally as take home
medication (oral dose = 2 X IV dose).
ifosfamide (IFEX) 3,105 mg in sodium chloride 0.9 % 250 mL bag
1,500 mg/m2 × 2.07 m2 (Treatment plan actual BSA) = 3,105 mg, Intravenous, EVERY 24 HOURS, 4 doses
Starting S+1 at 0000
Conditional Orders
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
IV push slowly, max rate 5 mg/minute.
lorazepam (ATIVAN) tab RANGE 0.5-1 mg
0.5-1 mg, Oral, EVERY 4 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
lorazepam (ATIVAN) injection 0.5-1 mg
0.5-1 mg, Intravenous, EVERY 4 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
IV push rate 2 mg/minute.
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
Take 2 tabs one time daily on Day 6, 7 and 8 then take 5 tabs by mouth 12 and 6 hours prior to PACLItaxel., Disp-
48 tab, R-1, starting S
prochlorperazine (COMPAZINE) 10 MG tab
Take 1 tab by mouth every 6 hours as needed for nausea/vomiting., Disp-30 tab, R-5, EVERY 6 HOURS PRN
starting S, Local Printer
lorazepam (ATIVAN) 1 MG tab
Take 1 tab by mouth every 6 hours as needed for nausea/vomiting., Disp-30 tab, R-5, EVERY 6 HOURS PRN
starting S, Local Printer
Take Home Medications (delete all that do not apply)
mesna (MESNEX) 400 MG tab
Take 5 tabs by mouth 2 times daily. Take 4 hours and 8 hours after start of last dose of ifosfamide., R-0, 2 X
DAILY starting S
Order if patient has not completed all inpatient IV mesna doses. Oral dose = 2 X IV dose. Round dose to nearest
200 mg.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
10/16/2012 10:23:32 AM Page 4 of 20
Copyright © 2012 University of Wisconsin Hospital and Clinics Authority



Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC without DIFF, ANC (CBC with DIFF if drawn locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) Schedule preadmission to B6/6 for chemotherapy administration.
Planned for 10/25/2012 Day 10 (Lab Only), Cycle 1 –
Treatment Plan Information
Reference Information (1)
TESTICULAR CANCER: Kondagunta G, et al. J Clin Oncol. 2005; 23(27):6549-55
Treatment Plan Summary
DISEASE: Testicular Cancer (Advanced); THERAPY: PACLItaxel 250 mg/m2 IV continuous infusion over 24
hours Day 1, CISplatin 25 mg/m2 IV Day 2 through 5, mesna 500 mg/m2 IV prior to ifosfamide and 4 hours and 8
hours after start of ifosfamide Day 2 through 5, ifosfamide 1500 mg/m2 IV Day 2 through 5; CYCLE LENGTH: 21
days; COURSE: 4 cycles; NOTE: If patient is discharged early, order oral mesna (oral dose = 2 X IV dose) for
remaining doses
Pre-Labs
Phlebotomist IV Access
Expected-S Approximate, Expires-S+365, If additional diagnostic tests or treatments that require venous access
are scheduled for the same day as laboratory testing, a qualified phlebotomist may place a peripheral IV or
access port for blood collection and leave access in place (PIV/PA).
CBC WITHOUT DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Normal, Routine
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride 0.9% flush 10 mL injection
Flush, PRN Starting S at 0000 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 S at 0000 Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 100 UNIT/ML injection 500 units
500 units, Flush, PRN Starting S at 0000 Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
11/6/2012 through 11/26/2012 (21 days), Planned Cycle 2 –
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
10/16/2012 10:23:32 AM Page 5 of 20
Copyright © 2012 University of Wisconsin Hospital and Clinics Authority


Planned for 11/6/2012 Day 1, Cycle 2 –
Treatment Plan Information
Reference Information (1)
TESTICULAR CANCER: Kondagunta G, et al. J Clin Oncol. 2005; 23(27):6549-55
Treatment Plan Summary
DISEASE: Testicular Cancer (Advanced); THERAPY: PACLItaxel 250 mg/m2 IV continuous infusion over 24
hours Day 1, CISplatin 25 mg/m2 IV Day 2 through 5, mesna 500 mg/m2 IV prior to ifosfamide and 4 hours and 8
hours after start of ifosfamide Day 2 through 5, ifosfamide 1500 mg/m2 IV Day 2 through 5; CYCLE LENGTH: 21
days; COURSE: 4 cycles; NOTE: If patient is discharged early, order oral mesna (oral dose = 2 X IV dose) for
remaining doses
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
ONCE Starting S at 0000
ABSOLUTE NEUTROPHIL COUNT
ONCE Starting S at 0000
ELECTROLYTES
ONCE Starting S at 0000
BUN
ONCE Starting S at 0000
CREATININE
ONCE Starting S at 0000
MAGNESIUM
ONCE Starting S at 0000
BILIRUBIN, TOTAL
ONCE Starting S at 0000
AST/SGOT
ONCE Starting S at 0000
ALT/SGPT
ONCE Starting S at 0000
ALBUMIN
ONCE Starting S at 0000
URINALYSIS WITH MICROSCOPY
NEXT AM Starting S+1 at 0000 until S+5 for 5 occurrences
Treatment Conditions
Verify Labs
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
10/16/2012 10:23:32 AM Page 6 of 20
Copyright © 2012 University of Wisconsin Hospital and Clinics Authority


Verify pretreatment labs have been obtained on Day 1: ANC, Platelets, Creatinine, Total Bilirubin, AST, ALT,
Albumin
Verify Labs (2)
Verify pretreatment labs have been obtained on Day 2 through 5: Urinalysis
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL, Platelets less than 75K/µL, Creatinine
greater than 2 mg/dL or Creatinine Clearance less than 50 mL/min, Total Bilirubin greater than 2 mg/dL, AST or
ALT greater than 3 X ULN or Albumin less than 3 gm/dL.
Treatment Parameters (2)
Hold treatment and notify authorizing prescriber for Urine RBC greater than 2/hpf prior to ifosfamide
administration on Day 2 through 5.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if
patient has not taken medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a
location to optimize emergency care. ** Rush dextrose primed line with 18mL prior to programming start rate for
infusion. ** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone). ** For
first and second doses, titrate up to full infusion rate over a minimum of 15 minutes. ** RN to stay at patient’s
bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction during
first dose.
Vital Signs
SEE COMMENTS Starting S at 0000 Until Specified, PACLItaxel: Monitor vital signs every 15 minutes for the first
hour then every 30 minutes for the remainder of the infusion for the first and second dose. If previous doses
tolerated, monitor vital signs every 30 minutes for all subsequent doses.
Monitoring Parameters (1)
Monitor for ifosfamide-related neurotoxicity (somnolence, agitation, confusion, delirium, hallucinations,
incontinence, palsy, diplopia or aphasia). Stop infusion and contact physician if toxicity is suspected.
Monitoring Parameters (2)
Monitor and notify physician for signs and symptoms of hemorrhagic cystitis (dysuria).
Measure Intake And Output
EVERY 4 HOURS Starting S+1 at 0000 Until Specified, Measure IV intake and urine output.
Flush Venous Access Device per Guidelines
Order details
sodium chloride 0.9% flush 10 mL injection
Flush, PRN Starting S at 0000 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 S at 0000 Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 100 UNIT/ML injection 500 units
500 units, Flush, PRN Starting S at 0000 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
Zztestonc,Jeff J [2507481]
10/16/2012 10:23:32 AM Page 7 of 20
Copyright © 2012 University of Wisconsin Hospital and Clinics Authority


sodium chloride 0.9 % infusion at 100 mL/hr, Intravenous, CONTINUOUS Starting S at 0000
Until Discontinued
Pre-Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released
Give 30 minutes prior to PACLItaxel.
for 1 Minutes
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released
Give 30 minutes prior to PACLItaxel.
for 5 Minutes
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting S+1 at 0000
Give prior to chemotherapy.
aprepitant (EMEND) cap 80 mg
80 mg, Oral, EVERY 24 HOURS, 2 doses Starting S+2 at 0000
Give prior to chemotherapy.
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9% 250mL bag
150 mg, Intravenous, ONCE, 1 dose Starting when released
Do not infuse with CA++, Mg++, Lactated Ringer's solutions
for 30 Minutes
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, EVERY 24 HOURS, 4 doses Starting S+1 at 0000
Give prior to chemotherapy. May give IV if unable to tolerate PO.
ondansetron (ZOFRAN) 24 mg in sodium chloride 0.9 % 50 mL bag
24 mg, Intravenous, EVERY 24 HOURS PRN, For 5 days Starting S+1 at 0000 until S+5 at 2359,
nausea/vomiting
Give prior to chemotherapy if patient unable to tolerate PO.
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, EVERY 24 HOURS, 4 doses Starting S+1
Give prior to chemotherapy. May give IV if unable to tolerate PO.
ondansetron (ZOFRAN) 12 mg in sodium chloride 0.9 % 50 mL bag
12 mg, Intravenous, EVERY 24 HOURS PRN, 4 doses Starting S+1, nausea/vomiting
Give prior to chemotherapy if patient unable to tolerate PO.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, EVERY 24 HOURS, 4 doses Starting S+1
Give prior to chemotherapy. May give IV if unable to tolerate PO.
dexamethasone (DECADRON) injection 8 mg
8 mg, Intravenous, EVERY 24 HOURS PRN, For 5 days Starting S+1, nausea/vomiting
Give prior to chemotherapy if patient unable to tolerate PO.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
10/16/2012 10:23:32 AM Page 8 of 20
Copyright © 2012 University of Wisconsin Hospital and Clinics Authority


diphenhydramine (BENADRYL) injection 50 mg 50 mg, Intravenous, PRN, 1 dose Starting
when released, infusion reaction, for 1 Minutes
dexamethasone (DECADRON) injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 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) 518 mg in dextrose 5 % 500 mL non-PVC bag
250 mg/m2 × 2.07 m2 (Treatment plan actual BSA) = 518 mg, Intravenous, ONCE, 1 dose Starting when released

Hypersensitivity risk. See emergency medications. Infuse over 24 hours. Use non-PVC tubing and 0.22 micron in-
line filter during administration
CISplatin (PLATINOL) 52 mg in sodium chloride 0.9 % 1,000 mL bag
25 mg/m2 × 2.07 m2 (Treatment plan actual BSA) = 52 mg, Intravenous, EVERY 24 HOURS, 4 doses Starting
S+1
For 60-120 minutes.
mesna (MESNEX) 1,035 mg in sodium chloride 0.9 % 50 mL bag
500 mg/m2 × 2.07 m2 (Treatment plan actual BSA) = 1,035 mg, Intravenous, 3 X DAILY, 12 doses Starting S+1
at 0000
Give prior to ifosfamide and 4 hours and 8 hours after start of ifosfamide infusion on Day 2 through 5. If patient
discharged prior to completing all IV mesna doses, remaining doses must be given orally as take home
medication (oral dose = 2 X IV dose).
ifosfamide (IFEX) 3,105 mg in sodium chloride 0.9 % 250 mL bag
1,500 mg/m2 × 2.07 m2 (Treatment plan actual BSA) = 3,105 mg, Intravenous, EVERY 24 HOURS, 4 doses
Starting S+1 at 0000
Conditional Orders
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
IV push slowly, max rate 5 mg/minute.
lorazepam (ATIVAN) tab RANGE 0.5-1 mg
0.5-1 mg, Oral, EVERY 4 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
lorazepam (ATIVAN) injection 0.5-1 mg
0.5-1 mg, Intravenous, EVERY 4 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
IV push rate 2 mg/minute.
Take Home Medications (delete all that do not apply)
mesna (MESNEX) 400 MG tab
Take 5 tabs by mouth 2 times daily. Take 4 hours and 8 hours after start of last dose of ifosfamide., R-0, 2 X
DAILY starting S
Order if patient has not completed all inpatient IV mesna doses. Oral dose = 2 X IV dose. Round dose to nearest
200 mg.
Follow-Up
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
10/16/2012 10:23:32 AM Page 9 of 20
Copyright © 2012 University of Wisconsin Hospital and Clinics Authority


DAY 10 FOLLOW-UP
LABS: CBC without DIFF, ANC (CBC with DIFF if drawn locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) Schedule preadmission to B6/6 for chemotherapy administration.
Planned for 11/15/2012 Day 10 (Lab Only), Cycle 2 –
Treatment Plan Information
Reference Information (1)
TESTICULAR CANCER: Kondagunta G, et al. J Clin Oncol. 2005; 23(27):6549-55
Treatment Plan Summary
DISEASE: Testicular Cancer (Advanced); THERAPY: PACLItaxel 250 mg/m2 IV continuous infusion over 24
hours Day 1, CISplatin 25 mg/m2 IV Day 2 through 5, mesna 500 mg/m2 IV prior to ifosfamide and 4 hours and 8
hours after start of ifosfamide Day 2 through 5, ifosfamide 1500 mg/m2 IV Day 2 through 5; CYCLE LENGTH: 21
days; COURSE: 4 cycles; NOTE: If patient is discharged early, order oral mesna (oral dose = 2 X IV dose) for
remaining doses
Pre-Labs
Phlebotomist IV Access
Expected-S Approximate, Expires-S+365, If additional diagnostic tests or treatments that require venous access
are scheduled for the same day as laboratory testing, a qualified phlebotomist may place a peripheral IV or
access port for blood collection and leave access in place (PIV/PA).
CBC WITHOUT DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Normal, Routine
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride 0.9% flush 10 mL injection
Flush, PRN Starting S at 0000 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 S at 0000 Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 100 UNIT/ML injection 500 units
500 units, Flush, PRN Starting S at 0000 Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
11/27/2012 through 12/17/2012 (21 days), Planned Cycle 3 –
Planned for 11/27/2012 Day 1, Cycle 3 –
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
10/16/2012 10:23:32 AM Page 10 of 20
Copyright © 2012 University of Wisconsin Hospital and Clinics Authority


Treatment Plan Information
Reference Information (1)
TESTICULAR CANCER: Kondagunta G, et al. J Clin Oncol. 2005; 23(27):6549-55
Treatment Plan Summary
DISEASE: Testicular Cancer (Advanced); THERAPY: PACLItaxel 250 mg/m2 IV continuous infusion over 24
hours Day 1, CISplatin 25 mg/m2 IV Day 2 through 5, mesna 500 mg/m2 IV prior to ifosfamide and 4 hours and 8
hours after start of ifosfamide Day 2 through 5, ifosfamide 1500 mg/m2 IV Day 2 through 5; CYCLE LENGTH: 21
days; COURSE: 4 cycles; NOTE: If patient is discharged early, order oral mesna (oral dose = 2 X IV dose) for
remaining doses
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
ONCE Starting S at 0000
ABSOLUTE NEUTROPHIL COUNT
ONCE Starting S at 0000
ELECTROLYTES
ONCE Starting S at 0000
BUN
ONCE Starting S at 0000
CREATININE
ONCE Starting S at 0000
MAGNESIUM
ONCE Starting S at 0000
BILIRUBIN, TOTAL
ONCE Starting S at 0000
AST/SGOT
ONCE Starting S at 0000
ALT/SGPT
ONCE Starting S at 0000
ALBUMIN
ONCE Starting S at 0000
URINALYSIS WITH MICROSCOPY
NEXT AM Starting S+1 at 0000 until S+5 for 5 occurrences
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained on Day 1: ANC, Platelets, Creatinine, Total Bilirubin, AST, ALT,
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
10/16/2012 10:23:32 AM Page 11 of 20
Copyright © 2012 University of Wisconsin Hospital and Clinics Authority


Albumin
Verify Labs (2)
Verify pretreatment labs have been obtained on Day 2 through 5: Urinalysis
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL, Platelets less than 75K/µL, Creatinine
greater than 2 mg/dL or Creatinine Clearance less than 50 mL/min, Total Bilirubin greater than 2 mg/dL, AST or
ALT greater than 3 X ULN or Albumin less than 3 gm/dL.
Treatment Parameters (2)
Hold treatment and notify authorizing prescriber for Urine RBC greater than 2/hpf prior to ifosfamide
administration on Day 2 through 5.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if
patient has not taken medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a
location to optimize emergency care. ** Rush dextrose primed line with 18mL prior to programming start rate for
infusion. ** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone). ** For
first and second doses, titrate up to full infusion rate over a minimum of 15 minutes. ** RN to stay at patient’s
bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction during
first dose.
Vital Signs
SEE COMMENTS Starting S at 0000 Until Specified, PACLItaxel: Monitor vital signs every 15 minutes for the first
hour then every 30 minutes for the remainder of the infusion for the first and second dose. If previous doses
tolerated, monitor vital signs every 30 minutes for all subsequent doses.
Monitoring Parameters (1)
Monitor for ifosfamide-related neurotoxicity (somnolence, agitation, confusion, delirium, hallucinations,
incontinence, palsy, diplopia or aphasia). Stop infusion and contact physician if toxicity is suspected.
Monitoring Parameters (2)
Monitor and notify physician for signs and symptoms of hemorrhagic cystitis (dysuria).
Measure Intake And Output
EVERY 4 HOURS Starting S+1 at 0000 Until Specified, Measure IV intake and urine output.
Flush Venous Access Device per Guidelines
Order details
sodium chloride 0.9% flush 10 mL injection
Flush, PRN Starting S at 0000 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 S at 0000 Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 100 UNIT/ML injection 500 units
500 units, Flush, PRN Starting S at 0000 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
Zztestonc,Jeff J [2507481]
10/16/2012 10:23:32 AM Page 12 of 20
Copyright © 2012 University of Wisconsin Hospital and Clinics Authority


at 100 mL/hr, Intravenous, CONTINUOUS Starting S at 0000 Until Discontinued
Pre-Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released
Give 30 minutes prior to PACLItaxel.
for 1 Minutes
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released
Give 30 minutes prior to PACLItaxel.
for 5 Minutes
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting S+1 at 0000
Give prior to chemotherapy.
aprepitant (EMEND) cap 80 mg
80 mg, Oral, EVERY 24 HOURS, 2 doses Starting S+2 at 0000
Give prior to chemotherapy.
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9% 250mL bag
150 mg, Intravenous, ONCE, 1 dose Starting when released
Do not infuse with CA++, Mg++, Lactated Ringer's solutions
for 30 Minutes
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, EVERY 24 HOURS, 4 doses Starting S+1 at 0000
Give prior to chemotherapy. May give IV if unable to tolerate PO.
ondansetron (ZOFRAN) 24 mg in sodium chloride 0.9 % 50 mL bag
24 mg, Intravenous, EVERY 24 HOURS PRN, For 5 days Starting S+1 at 0000 until S+5 at 2359,
nausea/vomiting
Give prior to chemotherapy if patient unable to tolerate PO.
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, EVERY 24 HOURS, 4 doses Starting S+1
Give prior to chemotherapy. May give IV if unable to tolerate PO.
ondansetron (ZOFRAN) 12 mg in sodium chloride 0.9 % 50 mL bag
12 mg, Intravenous, EVERY 24 HOURS PRN, 4 doses Starting S+1, nausea/vomiting
Give prior to chemotherapy if patient unable to tolerate PO.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, EVERY 24 HOURS, 4 doses Starting S+1
Give prior to chemotherapy. May give IV if unable to tolerate PO.
dexamethasone (DECADRON) injection 8 mg
8 mg, Intravenous, EVERY 24 HOURS PRN, For 5 days Starting S+1, nausea/vomiting
Give prior to chemotherapy if patient unable to tolerate PO.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
10/16/2012 10:23:32 AM Page 13 of 20
Copyright © 2012 University of Wisconsin Hospital and Clinics Authority


diphenhydramine (BENADRYL) injection 50 mg 50 mg, Intravenous, PRN, 1 dose Starting
when released, infusion reaction, for 1 Minutes
dexamethasone (DECADRON) injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 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) 518 mg in dextrose 5 % 500 mL non-PVC bag
250 mg/m2 × 2.07 m2 (Treatment plan actual BSA) = 518 mg, Intravenous, ONCE, 1 dose Starting when released

Hypersensitivity risk. See emergency medications. Infuse over 24 hours. Use non-PVC tubing and 0.22 micron in-
line filter during administration
CISplatin (PLATINOL) 52 mg in sodium chloride 0.9 % 1,000 mL bag
25 mg/m2 × 2.07 m2 (Treatment plan actual BSA) = 52 mg, Intravenous, EVERY 24 HOURS, 4 doses Starting
S+1
For 60-120 minutes.
mesna (MESNEX) 1,035 mg in sodium chloride 0.9 % 50 mL bag
500 mg/m2 × 2.07 m2 (Treatment plan actual BSA) = 1,035 mg, Intravenous, 3 X DAILY, 12 doses Starting S+1
at 0000
Give prior to ifosfamide and 4 hours and 8 hours after start of ifosfamide infusion on Day 2 through 5. If patient
discharged prior to completing all IV mesna doses, remaining doses must be given orally as take home
medication (oral dose = 2 X IV dose).
ifosfamide (IFEX) 3,105 mg in sodium chloride 0.9 % 250 mL bag
1,500 mg/m2 × 2.07 m2 (Treatment plan actual BSA) = 3,105 mg, Intravenous, EVERY 24 HOURS, 4 doses
Starting S+1 at 0000
Conditional Orders
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
IV push slowly, max rate 5 mg/minute.
lorazepam (ATIVAN) tab RANGE 0.5-1 mg
0.5-1 mg, Oral, EVERY 4 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
lorazepam (ATIVAN) injection 0.5-1 mg
0.5-1 mg, Intravenous, EVERY 4 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
IV push rate 2 mg/minute.
Take Home Medications (delete all that do not apply)
mesna (MESNEX) 400 MG tab
Take 5 tabs by mouth 2 times daily. Take 4 hours and 8 hours after start of last dose of ifosfamide., R-0, 2 X
DAILY starting S
Order if patient has not completed all inpatient IV mesna doses. Oral dose = 2 X IV dose. Round dose to nearest
200 mg.
Follow-Up
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
10/16/2012 10:23:32 AM Page 14 of 20
Copyright © 2012 University of Wisconsin Hospital and Clinics Authority


DAY 10 FOLLOW-UP
LABS: CBC without DIFF, ANC (CBC with DIFF if drawn locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) Schedule preadmission to B6/6 for chemotherapy administration.
Planned for 12/6/2012 Day 10 (Lab Only), Cycle 3 –
Treatment Plan Information
Reference Information (1)
TESTICULAR CANCER: Kondagunta G, et al. J Clin Oncol. 2005; 23(27):6549-55
Treatment Plan Summary
DISEASE: Testicular Cancer (Advanced); THERAPY: PACLItaxel 250 mg/m2 IV continuous infusion over 24
hours Day 1, CISplatin 25 mg/m2 IV Day 2 through 5, mesna 500 mg/m2 IV prior to ifosfamide and 4 hours and 8
hours after start of ifosfamide Day 2 through 5, ifosfamide 1500 mg/m2 IV Day 2 through 5; CYCLE LENGTH: 21
days; COURSE: 4 cycles; NOTE: If patient is discharged early, order oral mesna (oral dose = 2 X IV dose) for
remaining doses
Pre-Labs
Phlebotomist IV Access
Expected-S Approximate, Expires-S+365, If additional diagnostic tests or treatments that require venous access
are scheduled for the same day as laboratory testing, a qualified phlebotomist may place a peripheral IV or
access port for blood collection and leave access in place (PIV/PA).
CBC WITHOUT DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Normal, Routine
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride 0.9% flush 10 mL injection
Flush, PRN Starting S at 0000 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 S at 0000 Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 100 UNIT/ML injection 500 units
500 units, Flush, PRN Starting S at 0000 Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
12/18/2012 through 1/7/2013 (21 days), Planned Cycle 4 –
Planned for 12/18/2012 Day 1, Cycle 4 –
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
10/16/2012 10:23:32 AM Page 15 of 20
Copyright © 2012 University of Wisconsin Hospital and Clinics Authority


Treatment Plan Information
Reference Information (1)
TESTICULAR CANCER: Kondagunta G, et al. J Clin Oncol. 2005; 23(27):6549-55
Treatment Plan Summary
DISEASE: Testicular Cancer (Advanced); THERAPY: PACLItaxel 250 mg/m2 IV continuous infusion over 24
hours Day 1, CISplatin 25 mg/m2 IV Day 2 through 5, mesna 500 mg/m2 IV prior to ifosfamide and 4 hours and 8
hours after start of ifosfamide Day 2 through 5, ifosfamide 1500 mg/m2 IV Day 2 through 5; CYCLE LENGTH: 21
days; COURSE: 4 cycles; NOTE: If patient is discharged early, order oral mesna (oral dose = 2 X IV dose) for
remaining doses
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
ONCE Starting S at 0000
ABSOLUTE NEUTROPHIL COUNT
ONCE Starting S at 0000
ELECTROLYTES
ONCE Starting S at 0000
BUN
ONCE Starting S at 0000
CREATININE
ONCE Starting S at 0000
MAGNESIUM
ONCE Starting S at 0000
BILIRUBIN, TOTAL
ONCE Starting S at 0000
AST/SGOT
ONCE Starting S at 0000
ALT/SGPT
ONCE Starting S at 0000
ALBUMIN
ONCE Starting S at 0000
URINALYSIS WITH MICROSCOPY
NEXT AM Starting S+1 at 0000 until S+5 for 5 occurrences
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained on Day 1: ANC, Platelets, Creatinine, Total Bilirubin, AST, ALT,
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
10/16/2012 10:23:32 AM Page 16 of 20
Copyright © 2012 University of Wisconsin Hospital and Clinics Authority


Albumin
Verify Labs (2)
Verify pretreatment labs have been obtained on Day 2 through 5: Urinalysis
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL, Platelets less than 75K/µL, Creatinine
greater than 2 mg/dL or Creatinine Clearance less than 50 mL/min, Total Bilirubin greater than 2 mg/dL, AST or
ALT greater than 3 X ULN or Albumin less than 3 gm/dL.
Treatment Parameters (2)
Hold treatment and notify authorizing prescriber for Urine RBC greater than 2/hpf prior to ifosfamide
administration on Day 2 through 5.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if
patient has not taken medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a
location to optimize emergency care. ** Rush dextrose primed line with 18mL prior to programming start rate for
infusion. ** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone). ** For
first and second doses, titrate up to full infusion rate over a minimum of 15 minutes. ** RN to stay at patient’s
bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction during
first dose.
Vital Signs
SEE COMMENTS Starting S at 0000 Until Specified, PACLItaxel: Monitor vital signs every 15 minutes for the first
hour then every 30 minutes for the remainder of the infusion for the first and second dose. If previous doses
tolerated, monitor vital signs every 30 minutes for all subsequent doses.
Monitoring Parameters (1)
Monitor for ifosfamide-related neurotoxicity (somnolence, agitation, confusion, delirium, hallucinations,
incontinence, palsy, diplopia or aphasia). Stop infusion and contact physician if toxicity is suspected.
Monitoring Parameters (2)
Monitor and notify physician for signs and symptoms of hemorrhagic cystitis (dysuria).
Measure Intake And Output
EVERY 4 HOURS Starting S+1 at 0000 Until Specified, Measure IV intake and urine output.
Flush Venous Access Device per Guidelines
Order details
sodium chloride 0.9% flush 10 mL injection
Flush, PRN Starting S at 0000 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 S at 0000 Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 100 UNIT/ML injection 500 units
500 units, Flush, PRN Starting S at 0000 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
Zztestonc,Jeff J [2507481]
10/16/2012 10:23:32 AM Page 17 of 20
Copyright © 2012 University of Wisconsin Hospital and Clinics Authority


at 100 mL/hr, Intravenous, CONTINUOUS Starting S at 0000 Until Discontinued
Pre-Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released
Give 30 minutes prior to PACLItaxel.
for 1 Minutes
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released
Give 30 minutes prior to PACLItaxel.
for 5 Minutes
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting S+1 at 0000
Give prior to chemotherapy.
aprepitant (EMEND) cap 80 mg
80 mg, Oral, EVERY 24 HOURS, 2 doses Starting S+2 at 0000
Give prior to chemotherapy.
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9% 250mL bag
150 mg, Intravenous, ONCE, 1 dose Starting when released
Do not infuse with CA++, Mg++, Lactated Ringer's solutions
for 30 Minutes
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, EVERY 24 HOURS, 4 doses Starting S+1 at 0000
Give prior to chemotherapy. May give IV if unable to tolerate PO.
ondansetron (ZOFRAN) 24 mg in sodium chloride 0.9 % 50 mL bag
24 mg, Intravenous, EVERY 24 HOURS PRN, For 5 days Starting S+1 at 0000 until S+5 at 2359,
nausea/vomiting
Give prior to chemotherapy if patient unable to tolerate PO.
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, EVERY 24 HOURS, 4 doses Starting S+1
Give prior to chemotherapy. May give IV if unable to tolerate PO.
ondansetron (ZOFRAN) 12 mg in sodium chloride 0.9 % 50 mL bag
12 mg, Intravenous, EVERY 24 HOURS PRN, 4 doses Starting S+1, nausea/vomiting
Give prior to chemotherapy if patient unable to tolerate PO.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, EVERY 24 HOURS, 4 doses Starting S+1
Give prior to chemotherapy. May give IV if unable to tolerate PO.
dexamethasone (DECADRON) injection 8 mg
8 mg, Intravenous, EVERY 24 HOURS PRN, For 5 days Starting S+1, nausea/vomiting
Give prior to chemotherapy if patient unable to tolerate PO.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
10/16/2012 10:23:32 AM Page 18 of 20
Copyright © 2012 University of Wisconsin Hospital and Clinics Authority


diphenhydramine (BENADRYL) injection 50 mg 50 mg, Intravenous, PRN, 1 dose Starting
when released, infusion reaction, for 1 Minutes
dexamethasone (DECADRON) injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 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) 518 mg in dextrose 5 % 500 mL non-PVC bag
250 mg/m2 × 2.07 m2 (Treatment plan actual BSA) = 518 mg, Intravenous, ONCE, 1 dose Starting when released

Hypersensitivity risk. See emergency medications. Infuse over 24 hours. Use non-PVC tubing and 0.22 micron in-
line filter during administration
CISplatin (PLATINOL) 52 mg in sodium chloride 0.9 % 1,000 mL bag
25 mg/m2 × 2.07 m2 (Treatment plan actual BSA) = 52 mg, Intravenous, EVERY 24 HOURS, 4 doses Starting
S+1
For 60-120 minutes.
mesna (MESNEX) 1,035 mg in sodium chloride 0.9 % 50 mL bag
500 mg/m2 × 2.07 m2 (Treatment plan actual BSA) = 1,035 mg, Intravenous, 3 X DAILY, 12 doses Starting S+1
at 0000
Give prior to ifosfamide and 4 hours and 8 hours after start of ifosfamide infusion on Day 2 through 5. If patient
discharged prior to completing all IV mesna doses, remaining doses must be given orally as take home
medication (oral dose = 2 X IV dose).
ifosfamide (IFEX) 3,105 mg in sodium chloride 0.9 % 250 mL bag
1,500 mg/m2 × 2.07 m2 (Treatment plan actual BSA) = 3,105 mg, Intravenous, EVERY 24 HOURS, 4 doses
Starting S+1 at 0000
Conditional Orders
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
IV push slowly, max rate 5 mg/minute.
lorazepam (ATIVAN) tab RANGE 0.5-1 mg
0.5-1 mg, Oral, EVERY 4 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
lorazepam (ATIVAN) injection 0.5-1 mg
0.5-1 mg, Intravenous, EVERY 4 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
IV push rate 2 mg/minute.
Take Home Medications (delete all that do not apply)
mesna (MESNEX) 400 MG tab
Take 5 tabs by mouth 2 times daily. Take 4 hours and 8 hours after start of last dose of ifosfamide., R-0, 2 X
DAILY starting S
Order if patient has not completed all inpatient IV mesna doses. Oral dose = 2 X IV dose. Round dose to nearest
200 mg.
Follow-Up
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
10/16/2012 10:23:32 AM Page 19 of 20
Copyright © 2012 University of Wisconsin Hospital and Clinics Authority


DAY 10 FOLLOW-UP
LABS: CBC without DIFF, ANC (CBC with DIFF if drawn locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) Schedule preadmission to B6/6 for chemotherapy administration.
Planned for 12/27/2012 Day 10 (Lab Only), Cycle 4 –
Treatment Plan Information
Reference Information (1)
TESTICULAR CANCER: Kondagunta G, et al. J Clin Oncol. 2005; 23(27):6549-55
Treatment Plan Summary
DISEASE: Testicular Cancer (Advanced); THERAPY: PACLItaxel 250 mg/m2 IV continuous infusion over 24
hours Day 1, CISplatin 25 mg/m2 IV Day 2 through 5, mesna 500 mg/m2 IV prior to ifosfamide and 4 hours and 8
hours after start of ifosfamide Day 2 through 5, ifosfamide 1500 mg/m2 IV Day 2 through 5; CYCLE LENGTH: 21
days; COURSE: 4 cycles; NOTE: If patient is discharged early, order oral mesna (oral dose = 2 X IV dose) for
remaining doses
Pre-Labs
Phlebotomist IV Access
Expected-S Approximate, Expires-S+365, If additional diagnostic tests or treatments that require venous access
are scheduled for the same day as laboratory testing, a qualified phlebotomist may place a peripheral IV or
access port for blood collection and leave access in place (PIV/PA).
CBC WITHOUT DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Normal, Routine
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride 0.9% flush 10 mL injection
Flush, PRN Starting S at 0000 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 S at 0000 Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 100 UNIT/ML injection 500 units
500 units, Flush, PRN Starting S at 0000 Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
10/16/2012 10:23:32 AM Page 20 of 20
Copyright © 2012 University of Wisconsin Hospital and Clinics Authority