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

CSC GYN Ifosfamide Mesna(21D:1-5) Prior XRT VER 1-11-17 (HL 474)

CSC GYN Ifosfamide Mesna(21D:1-5) Prior XRT VER 1-11-17 (HL 474) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GYN


CSC GYN IFOSFAMIDE/MESNA (21D:1-5) PRIOR XRT VER: 1-11-17 – Properties
Pre-Cycle – 5/30/2017 through 6/5/2017 (7 days), Planned
Day 1, Pre-Cycle – Planned for 5/30/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical Cancer (Advanced), Vulvar, Vaginal (Advanced) and Uterine Sarcoma (Adjuvant/Advanced); THERAPY: mesna
400 mg/m2 IV prior to start of ifosfomide Day 1 through 5; ifosfamide 1200 mg/m2 IV on Day 1 through 5; mesna 400 mg/m2 by
mouth 4 hours and 8 hours after the start of ifosfamide; CYCLE LENGTH:21 days; COURSE: 3 to 6 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
ELECTROLYTES
Expected-S Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S Approximate, Expires-S+365, Routine
BUN
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
URINALYSIS, NO MICROSCOPY
Expected-S Approximate, Expires-S+365, Normal, Routine
Take Home Medications
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab orally twice daily on Day 6 and 7 then 1 tab every 8h as needed for nausea, Disp-30 tab, R-5, starting S, Local Printer
Cycle 1 – 6/6/2017 through 6/26/2017 (21 days), Planned
Day 1, Cycle 1 – Planned for 6/6/2017
Treatment Plan Information
Reference Information (1)
CERVICAL CANCER: Sutton G, et al. Am J Obstet Gynecol 1993; 168:805-7.
Reference Information (2)
UTERINE SARCOMA: Sutton G, et al. Am J Obstet Gynecol 1998; 161:309-12.
Treatment Plan Summary
DISEASE: Cervical Cancer (Advanced), Vulvar, Vaginal (Advanced) and Uterine Sarcoma (Adjuvant/Advanced); THERAPY: mesna
400 mg/m2 IV prior to start of ifosfomide Day 1 through 5; ifosfamide 1200 mg/m2 IV on Day 1 through 5; mesna 400 mg/m2 by
mouth 4 hours and 8 hours after the start of ifosfamide; CYCLE LENGTH:21 days; COURSE: 3 to 6 cycles.
Consent
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Zztestonc,Edward E [2435061]
6/6/2017 5:12:55 PM Page 1 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: CBC, ANC, Urine Heme, Creatinine
Monitoring Parameters (1)
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Urine
Hemoglobin greater than Trace or Creatinine greater than upper limits of normal.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
mesna (MESNEX) 800 mg in sodium chloride 0.9 % 50 mL bag
800 mg (400 mg/m2 × 2 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) 2,400 mg in sodium chloride 0.9 % 250 mL bag
2,400 mg (1,200 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Take Home Medications
mesna (MESNEX) 400 MG tab
Take 2 tabs by mouth 2 times daily. Take 4 hours and 8 hours after the start of ifosfamide on Day 1 through 5 for 10 doses., 800
mg (400 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
Follow-Up
DAY 2 FOLLOW-UP
LABS: Urinalysis - no microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide and mesna for 200 minutes.
DAY 3 FOLLOW-UP
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Zztestonc,Edward E [2435061]
6/6/2017 5:12:55 PM Page 2 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

LABS: Urinalysis - no microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide and mesna for 200
minutes.
DAY 4 FOLLOW-UP
LABS: Urinalysis - no microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide and mesna for 200 minutes.
DAY 5 FOLLOW-UP
LABS: Urinalysis - no microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide and mesna for 200 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 to be done locally), Electrolytes,
Magnesium, Glucose, BUN, Creatinine, Urinalysis - no microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide and
mesna for 200 minutes.
Day 2, Cycle 1 – Planned for 6/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical Cancer (Advanced), Vulvar, Vaginal (Advanced) and Uterine Sarcoma (Adjuvant/Advanced); THERAPY: mesna
400 mg/m2 IV prior to start of ifosfomide Day 1 through 5; ifosfamide 1200 mg/m2 IV on Day 1 through 5; mesna 400 mg/m2 by
mouth 4 hours and 8 hours after the start of ifosfamide; CYCLE LENGTH:21 days; COURSE: 3 to 6 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
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
ondansetron (ZOFRAN) tab 16 mg
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Zztestonc,Edward E [2435061]
6/6/2017 5:12:55 PM Page 3 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
mesna (MESNEX) 800 mg in sodium chloride 0.9 % 50 mL bag
800 mg (400 mg/m2 × 2 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) 2,400 mg in sodium chloride 0.9 % 250 mL bag
2,400 mg (1,200 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
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 6/8/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical Cancer (Advanced), Vulvar, Vaginal (Advanced) and Uterine Sarcoma (Adjuvant/Advanced); THERAPY: mesna
400 mg/m2 IV prior to start of ifosfomide Day 1 through 5; ifosfamide 1200 mg/m2 IV on Day 1 through 5; mesna 400 mg/m2 by
mouth 4 hours and 8 hours after the start of ifosfamide; CYCLE LENGTH:21 days; COURSE: 3 to 6 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
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,Edward E [2435061]
6/6/2017 5:12:55 PM Page 4 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
mesna (MESNEX) 800 mg in sodium chloride 0.9 % 50 mL bag
800 mg (400 mg/m2 × 2 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) 2,400 mg in sodium chloride 0.9 % 250 mL bag
2,400 mg (1,200 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
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 6/9/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical Cancer (Advanced), Vulvar, Vaginal (Advanced) and Uterine Sarcoma (Adjuvant/Advanced); THERAPY: mesna
400 mg/m2 IV prior to start of ifosfomide Day 1 through 5; ifosfamide 1200 mg/m2 IV on Day 1 through 5; mesna 400 mg/m2 by
mouth 4 hours and 8 hours after the start of ifosfamide; CYCLE LENGTH:21 days; COURSE: 3 to 6 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
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.
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Zztestonc,Edward E [2435061]
6/6/2017 5:12:55 PM Page 5 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
mesna (MESNEX) 800 mg in sodium chloride 0.9 % 50 mL bag
800 mg (400 mg/m2 × 2 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) 2,400 mg in sodium chloride 0.9 % 250 mL bag
2,400 mg (1,200 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
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 6/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical Cancer (Advanced), Vulvar, Vaginal (Advanced) and Uterine Sarcoma (Adjuvant/Advanced); THERAPY: mesna
400 mg/m2 IV prior to start of ifosfomide Day 1 through 5; ifosfamide 1200 mg/m2 IV on Day 1 through 5; mesna 400 mg/m2 by
mouth 4 hours and 8 hours after the start of ifosfamide; CYCLE LENGTH:21 days; COURSE: 3 to 6 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
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
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Zztestonc,Edward E [2435061]
6/6/2017 5:12:55 PM Page 6 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
mesna (MESNEX) 800 mg in sodium chloride 0.9 % 50 mL bag
800 mg (400 mg/m2 × 2 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) 2,400 mg in sodium chloride 0.9 % 250 mL bag
2,400 mg (1,200 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 10 - Lab Only, Cycle 1 – Planned for 6/15/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical Cancer (Advanced), Vulvar, Vaginal (Advanced) and Uterine Sarcoma (Adjuvant/Advanced); THERAPY: mesna
400 mg/m2 IV prior to start of ifosfomide Day 1 through 5; ifosfamide 1200 mg/m2 IV on Day 1 through 5; mesna 400 mg/m2 by
mouth 4 hours and 8 hours after the start of ifosfamide; CYCLE LENGTH:21 days; COURSE: 3 to 6 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 – 6/27/2017 through 7/17/2017 (21 days), Planned
Day 1, Cycle 2 – Planned for 6/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical Cancer (Advanced), Vulvar, Vaginal (Advanced) and Uterine Sarcoma (Adjuvant/Advanced); THERAPY: mesna
400 mg/m2 IV prior to start of ifosfomide Day 1 through 5; ifosfamide 1200 mg/m2 IV on Day 1 through 5; mesna 400 mg/m2 by
mouth 4 hours and 8 hours after the start of ifosfamide; CYCLE LENGTH:21 days; COURSE: 3 to 6 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
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Zztestonc,Edward E [2435061]
6/6/2017 5:12:55 PM Page 7 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+17 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+17 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+17 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+17 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+17 Approximate, Expires-S+365, Routine
BUN
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
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: CBC, ANC, Urine Heme, Creatinine
Monitoring Parameters (1)
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Urine
Hemoglobin greater than Trace or Creatinine greater than upper limits of normal.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
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Zztestonc,Edward E [2435061]
6/6/2017 5:12:55 PM Page 8 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

mesna (MESNEX) 800 mg in sodium chloride 0.9 % 50 mL bag
800 mg (400 mg/m2 × 2 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) 2,400 mg in sodium chloride 0.9 % 250 mL bag
2,400 mg (1,200 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Take Home Medications
mesna (MESNEX) 400 MG tab
Take 2 tabs by mouth 2 times daily. Take 4 hours and 8 hours after the start of ifosfamide on Day 1 through 5 for 10 doses., 800
mg (400 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
Follow-Up
DAY 2 FOLLOW-UP
LABS: Urinalysis - no microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide and mesna for 200 minutes.
DAY 3 FOLLOW-UP
LABS: Urinalysis - no microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide and mesna for 200 minutes.
DAY 4 FOLLOW-UP
LABS: Urinalysis - no microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide and mesna for 200 minutes.
DAY 5 FOLLOW-UP
LABS: Urinalysis - no microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide and mesna for 200 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 to be done locally), Electrolytes,
Magnesium, Glucose, BUN, Creatinine, Urinalysis - no microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide and
mesna for 200 minutes.
Day 2, Cycle 2 – Planned for 6/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical Cancer (Advanced), Vulvar, Vaginal (Advanced) and Uterine Sarcoma (Adjuvant/Advanced); THERAPY: mesna
400 mg/m2 IV prior to start of ifosfomide Day 1 through 5; ifosfamide 1200 mg/m2 IV on Day 1 through 5; mesna 400 mg/m2 by
mouth 4 hours and 8 hours after the start of ifosfamide; CYCLE LENGTH:21 days; COURSE: 3 to 6 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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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Zztestonc,Edward E [2435061]
6/6/2017 5:12:55 PM Page 9 of 39
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
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
mesna (MESNEX) 800 mg in sodium chloride 0.9 % 50 mL bag
800 mg (400 mg/m2 × 2 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) 2,400 mg in sodium chloride 0.9 % 250 mL bag
2,400 mg (1,200 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
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 6/29/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical Cancer (Advanced), Vulvar, Vaginal (Advanced) and Uterine Sarcoma (Adjuvant/Advanced); THERAPY: mesna
400 mg/m2 IV prior to start of ifosfomide Day 1 through 5; ifosfamide 1200 mg/m2 IV on Day 1 through 5; mesna 400 mg/m2 by
mouth 4 hours and 8 hours after the start of ifosfamide; CYCLE LENGTH:21 days; COURSE: 3 to 6 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
Flush Venous Access Device per Guidelines
Order details
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Zztestonc,Edward E [2435061]
6/6/2017 5:12:55 PM Page 10 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
mesna (MESNEX) 800 mg in sodium chloride 0.9 % 50 mL bag
800 mg (400 mg/m2 × 2 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) 2,400 mg in sodium chloride 0.9 % 250 mL bag
2,400 mg (1,200 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
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 6/30/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical Cancer (Advanced), Vulvar, Vaginal (Advanced) and Uterine Sarcoma (Adjuvant/Advanced); THERAPY: mesna
400 mg/m2 IV prior to start of ifosfomide Day 1 through 5; ifosfamide 1200 mg/m2 IV on Day 1 through 5; mesna 400 mg/m2 by
mouth 4 hours and 8 hours after the start of ifosfamide; CYCLE LENGTH:21 days; COURSE: 3 to 6 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
Flush Venous Access Device per Guidelines
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Zztestonc,Edward E [2435061]
6/6/2017 5:12:55 PM Page 11 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
mesna (MESNEX) 800 mg in sodium chloride 0.9 % 50 mL bag
800 mg (400 mg/m2 × 2 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) 2,400 mg in sodium chloride 0.9 % 250 mL bag
2,400 mg (1,200 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
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 7/1/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical Cancer (Advanced), Vulvar, Vaginal (Advanced) and Uterine Sarcoma (Adjuvant/Advanced); THERAPY: mesna
400 mg/m2 IV prior to start of ifosfomide Day 1 through 5; ifosfamide 1200 mg/m2 IV on Day 1 through 5; mesna 400 mg/m2 by
mouth 4 hours and 8 hours after the start of ifosfamide; CYCLE LENGTH:21 days; COURSE: 3 to 6 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
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Zztestonc,Edward E [2435061]
6/6/2017 5:12:55 PM Page 12 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
mesna (MESNEX) 800 mg in sodium chloride 0.9 % 50 mL bag
800 mg (400 mg/m2 × 2 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) 2,400 mg in sodium chloride 0.9 % 250 mL bag
2,400 mg (1,200 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 10 - Lab Only, Cycle 2 – Planned for 7/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical Cancer (Advanced), Vulvar, Vaginal (Advanced) and Uterine Sarcoma (Adjuvant/Advanced); THERAPY: mesna
400 mg/m2 IV prior to start of ifosfomide Day 1 through 5; ifosfamide 1200 mg/m2 IV on Day 1 through 5; mesna 400 mg/m2 by
mouth 4 hours and 8 hours after the start of ifosfamide; CYCLE LENGTH:21 days; COURSE: 3 to 6 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,Edward E [2435061]
6/6/2017 5:12:55 PM Page 13 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Cycle 3 – 7/18/2017 through 8/7/2017 (21 days), Planned
Day 1, Cycle 3 – Planned for 7/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical Cancer (Advanced), Vulvar, Vaginal (Advanced) and Uterine Sarcoma (Adjuvant/Advanced); THERAPY: mesna
400 mg/m2 IV prior to start of ifosfomide Day 1 through 5; ifosfamide 1200 mg/m2 IV on Day 1 through 5; mesna 400 mg/m2 by
mouth 4 hours and 8 hours after the start of ifosfamide; CYCLE LENGTH:21 days; COURSE: 3 to 6 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
ELECTROLYTES
Expected-S+17 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+17 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+17 Approximate, Expires-S+365, Routine
BUN
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
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: CBC, ANC, Urine Heme, Creatinine
Monitoring Parameters (1)
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Urine
Hemoglobin greater than Trace or Creatinine greater than upper limits of normal.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
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Zztestonc,Edward E [2435061]
6/6/2017 5:12:55 PM Page 14 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
mesna (MESNEX) 800 mg in sodium chloride 0.9 % 50 mL bag
800 mg (400 mg/m2 × 2 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) 2,400 mg in sodium chloride 0.9 % 250 mL bag
2,400 mg (1,200 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Take Home Medications
mesna (MESNEX) 400 MG tab
Take 2 tabs by mouth 2 times daily. Take 4 hours and 8 hours after the start of ifosfamide on Day 1 through 5 for 10 doses., 800
mg (400 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
Follow-Up
DAY 2 FOLLOW-UP
LABS: Urinalysis - no microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide and mesna for 200 minutes.
DAY 3 FOLLOW-UP
LABS: Urinalysis - no microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide and mesna for 200 minutes.
DAY 4 FOLLOW-UP
LABS: Urinalysis - no microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide and mesna for 200 minutes.
DAY 5 FOLLOW-UP
LABS: Urinalysis - no microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide and mesna for 200 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 to be done locally), Electrolytes,
Magnesium, Glucose, BUN, Creatinine, Urinalysis - no microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide and
mesna for 200 minutes.
Day 2, Cycle 3 – Planned for 7/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical Cancer (Advanced), Vulvar, Vaginal (Advanced) and Uterine Sarcoma (Adjuvant/Advanced); THERAPY: mesna
400 mg/m2 IV prior to start of ifosfomide Day 1 through 5; ifosfamide 1200 mg/m2 IV on Day 1 through 5; mesna 400 mg/m2 by
mouth 4 hours and 8 hours after the start of ifosfamide; CYCLE LENGTH:21 days; COURSE: 3 to 6 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
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Zztestonc,Edward E [2435061]
6/6/2017 5:12:55 PM Page 15 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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
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
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
mesna (MESNEX) 800 mg in sodium chloride 0.9 % 50 mL bag
800 mg (400 mg/m2 × 2 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) 2,400 mg in sodium chloride 0.9 % 250 mL bag
2,400 mg (1,200 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
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 7/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical Cancer (Advanced), Vulvar, Vaginal (Advanced) and Uterine Sarcoma (Adjuvant/Advanced); THERAPY: mesna
400 mg/m2 IV prior to start of ifosfomide Day 1 through 5; ifosfamide 1200 mg/m2 IV on Day 1 through 5; mesna 400 mg/m2 by
mouth 4 hours and 8 hours after the start of ifosfamide; CYCLE LENGTH:21 days; COURSE: 3 to 6 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
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Zztestonc,Edward E [2435061]
6/6/2017 5:12:55 PM Page 16 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

URINALYSIS, NO MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: Urine Heme.
Treatment Parameters
Hold and notify authorizing prescriber for Urine Hemoglobin greater than Trace.
Nursing Procedure, Assessment and Monitoring
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
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
mesna (MESNEX) 800 mg in sodium chloride 0.9 % 50 mL bag
800 mg (400 mg/m2 × 2 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) 2,400 mg in sodium chloride 0.9 % 250 mL bag
2,400 mg (1,200 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
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 7/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical Cancer (Advanced), Vulvar, Vaginal (Advanced) and Uterine Sarcoma (Adjuvant/Advanced); THERAPY: mesna
400 mg/m2 IV prior to start of ifosfomide Day 1 through 5; ifosfamide 1200 mg/m2 IV on Day 1 through 5; mesna 400 mg/m2 by
mouth 4 hours and 8 hours after the start of ifosfamide; CYCLE LENGTH:21 days; COURSE: 3 to 6 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.
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Zztestonc,Edward E [2435061]
6/6/2017 5:12:55 PM Page 17 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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
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
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
mesna (MESNEX) 800 mg in sodium chloride 0.9 % 50 mL bag
800 mg (400 mg/m2 × 2 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) 2,400 mg in sodium chloride 0.9 % 250 mL bag
2,400 mg (1,200 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
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 7/22/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical Cancer (Advanced), Vulvar, Vaginal (Advanced) and Uterine Sarcoma (Adjuvant/Advanced); THERAPY: mesna
400 mg/m2 IV prior to start of ifosfomide Day 1 through 5; ifosfamide 1200 mg/m2 IV on Day 1 through 5; mesna 400 mg/m2 by
mouth 4 hours and 8 hours after the start of ifosfamide; CYCLE LENGTH:21 days; COURSE: 3 to 6 cycles.
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Edward E [2435061]
6/6/2017 5:12:55 PM Page 18 of 39
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
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
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
mesna (MESNEX) 800 mg in sodium chloride 0.9 % 50 mL bag
800 mg (400 mg/m2 × 2 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) 2,400 mg in sodium chloride 0.9 % 250 mL bag
2,400 mg (1,200 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 10 - Lab Only, Cycle 3 – Planned for 7/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical Cancer (Advanced), Vulvar, Vaginal (Advanced) and Uterine Sarcoma (Adjuvant/Advanced); THERAPY: mesna
400 mg/m2 IV prior to start of ifosfomide Day 1 through 5; ifosfamide 1200 mg/m2 IV on Day 1 through 5; mesna 400 mg/m2 by
mouth 4 hours and 8 hours after the start of ifosfamide; CYCLE LENGTH:21 days; COURSE: 3 to 6 cycles.
IV Access
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Zztestonc,Edward E [2435061]
6/6/2017 5:12:55 PM Page 19 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+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 – 8/8/2017 through 8/28/2017 (21 days), Planned
Day 1, Cycle 4 – Planned for 8/8/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical Cancer (Advanced), Vulvar, Vaginal (Advanced) and Uterine Sarcoma (Adjuvant/Advanced); THERAPY: mesna
400 mg/m2 IV prior to start of ifosfomide Day 1 through 5; ifosfamide 1200 mg/m2 IV on Day 1 through 5; mesna 400 mg/m2 by
mouth 4 hours and 8 hours after the start of ifosfamide; CYCLE LENGTH:21 days; COURSE: 3 to 6 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
ELECTROLYTES
Expected-S+17 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+17 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+17 Approximate, Expires-S+365, Routine
BUN
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
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: CBC, ANC, Urine Heme, Creatinine
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Zztestonc,Edward E [2435061]
6/6/2017 5:12:55 PM Page 20 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Monitoring Parameters (1)
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Urine
Hemoglobin greater than Trace or Creatinine greater than upper limits of normal.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
mesna (MESNEX) 800 mg in sodium chloride 0.9 % 50 mL bag
800 mg (400 mg/m2 × 2 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) 2,400 mg in sodium chloride 0.9 % 250 mL bag
2,400 mg (1,200 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Take Home Medications
mesna (MESNEX) 400 MG tab
Take 2 tabs by mouth 2 times daily. Take 4 hours and 8 hours after the start of ifosfamide on Day 1 through 5 for 10 doses., 800
mg (400 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
Follow-Up
DAY 2 FOLLOW-UP
LABS: Urinalysis - no microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide and mesna for 200 minutes.
DAY 3 FOLLOW-UP
LABS: Urinalysis - no microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide and mesna for 200 minutes.
DAY 4 FOLLOW-UP
LABS: Urinalysis - no microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide and mesna for 200 minutes.
DAY 5 FOLLOW-UP
LABS: Urinalysis - no microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide and mesna for 200 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 to be done locally), Electrolytes,
Magnesium, Glucose, BUN, Creatinine, Urinalysis - no microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide and
mesna for 200 minutes.
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Zztestonc,Edward E [2435061]
6/6/2017 5:12:55 PM Page 21 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Day 2, Cycle 4 – Planned for 8/9/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical Cancer (Advanced), Vulvar, Vaginal (Advanced) and Uterine Sarcoma (Adjuvant/Advanced); THERAPY: mesna
400 mg/m2 IV prior to start of ifosfomide Day 1 through 5; ifosfamide 1200 mg/m2 IV on Day 1 through 5; mesna 400 mg/m2 by
mouth 4 hours and 8 hours after the start of ifosfamide; CYCLE LENGTH:21 days; COURSE: 3 to 6 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
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
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
mesna (MESNEX) 800 mg in sodium chloride 0.9 % 50 mL bag
800 mg (400 mg/m2 × 2 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) 2,400 mg in sodium chloride 0.9 % 250 mL bag
2,400 mg (1,200 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
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Zztestonc,Edward E [2435061]
6/6/2017 5:12:55 PM Page 22 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 4 – Planned for 8/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical Cancer (Advanced), Vulvar, Vaginal (Advanced) and Uterine Sarcoma (Adjuvant/Advanced); THERAPY: mesna
400 mg/m2 IV prior to start of ifosfomide Day 1 through 5; ifosfamide 1200 mg/m2 IV on Day 1 through 5; mesna 400 mg/m2 by
mouth 4 hours and 8 hours after the start of ifosfamide; CYCLE LENGTH:21 days; COURSE: 3 to 6 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
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
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
mesna (MESNEX) 800 mg in sodium chloride 0.9 % 50 mL bag
800 mg (400 mg/m2 × 2 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) 2,400 mg in sodium chloride 0.9 % 250 mL bag
2,400 mg (1,200 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
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Zztestonc,Edward E [2435061]
6/6/2017 5:12:55 PM Page 23 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 4, Cycle 4 – Planned for 8/11/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical Cancer (Advanced), Vulvar, Vaginal (Advanced) and Uterine Sarcoma (Adjuvant/Advanced); THERAPY: mesna
400 mg/m2 IV prior to start of ifosfomide Day 1 through 5; ifosfamide 1200 mg/m2 IV on Day 1 through 5; mesna 400 mg/m2 by
mouth 4 hours and 8 hours after the start of ifosfamide; CYCLE LENGTH:21 days; COURSE: 3 to 6 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
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
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
mesna (MESNEX) 800 mg in sodium chloride 0.9 % 50 mL bag
800 mg (400 mg/m2 × 2 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) 2,400 mg in sodium chloride 0.9 % 250 mL bag
2,400 mg (1,200 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
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Zztestonc,Edward E [2435061]
6/6/2017 5:12:55 PM Page 24 of 39
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 5, Cycle 4 – Planned for 8/12/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical Cancer (Advanced), Vulvar, Vaginal (Advanced) and Uterine Sarcoma (Adjuvant/Advanced); THERAPY: mesna
400 mg/m2 IV prior to start of ifosfomide Day 1 through 5; ifosfamide 1200 mg/m2 IV on Day 1 through 5; mesna 400 mg/m2 by
mouth 4 hours and 8 hours after the start of ifosfamide; CYCLE LENGTH:21 days; COURSE: 3 to 6 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
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
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
mesna (MESNEX) 800 mg in sodium chloride 0.9 % 50 mL bag
800 mg (400 mg/m2 × 2 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) 2,400 mg in sodium chloride 0.9 % 250 mL bag
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Zztestonc,Edward E [2435061]
6/6/2017 5:12:55 PM Page 25 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

2,400 mg (1,200 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 10 - Lab Only, Cycle 4 – Planned for 8/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical Cancer (Advanced), Vulvar, Vaginal (Advanced) and Uterine Sarcoma (Adjuvant/Advanced); THERAPY: mesna
400 mg/m2 IV prior to start of ifosfomide Day 1 through 5; ifosfamide 1200 mg/m2 IV on Day 1 through 5; mesna 400 mg/m2 by
mouth 4 hours and 8 hours after the start of ifosfamide; CYCLE LENGTH:21 days; COURSE: 3 to 6 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 5 – 8/29/2017 through 9/18/2017 (21 days), Planned
Day 1, Cycle 5 – Planned for 8/29/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical Cancer (Advanced), Vulvar, Vaginal (Advanced) and Uterine Sarcoma (Adjuvant/Advanced); THERAPY: mesna
400 mg/m2 IV prior to start of ifosfomide Day 1 through 5; ifosfamide 1200 mg/m2 IV on Day 1 through 5; mesna 400 mg/m2 by
mouth 4 hours and 8 hours after the start of ifosfamide; CYCLE LENGTH:21 days; COURSE: 3 to 6 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
ELECTROLYTES
Expected-S+17 Approximate, Expires-S+365, Routine
MAGNESIUM
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Zztestonc,Edward E [2435061]
6/6/2017 5:12:55 PM Page 26 of 39
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
GLUCOSE
Expected-S+17 Approximate, Expires-S+365, Routine
BUN
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
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: CBC, ANC, Urine Heme, Creatinine
Monitoring Parameters (1)
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Urine
Hemoglobin greater than Trace or Creatinine greater than upper limits of normal.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
mesna (MESNEX) 800 mg in sodium chloride 0.9 % 50 mL bag
800 mg (400 mg/m2 × 2 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) 2,400 mg in sodium chloride 0.9 % 250 mL bag
2,400 mg (1,200 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Take Home Medications
mesna (MESNEX) 400 MG tab
Take 2 tabs by mouth 2 times daily. Take 4 hours and 8 hours after the start of ifosfamide on Day 1 through 5 for 10 doses., 800
mg (400 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
Follow-Up
DAY 2 FOLLOW-UP
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Zztestonc,Edward E [2435061]
6/6/2017 5:12:55 PM Page 27 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

LABS: Urinalysis - no microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide and mesna for 200 minutes.
DAY 3 FOLLOW-UP
LABS: Urinalysis - no microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide and mesna for 200 minutes.
DAY 4 FOLLOW-UP
LABS: Urinalysis - no microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide and mesna for 200 minutes.
DAY 5 FOLLOW-UP
LABS: Urinalysis - no microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide and mesna for 200 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 to be done locally), Electrolytes,
Magnesium, Glucose, BUN, Creatinine, Urinalysis - no microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide and
mesna for 200 minutes.
Day 2, Cycle 5 – Planned for 8/30/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical Cancer (Advanced), Vulvar, Vaginal (Advanced) and Uterine Sarcoma (Adjuvant/Advanced); THERAPY: mesna
400 mg/m2 IV prior to start of ifosfomide Day 1 through 5; ifosfamide 1200 mg/m2 IV on Day 1 through 5; mesna 400 mg/m2 by
mouth 4 hours and 8 hours after the start of ifosfamide; CYCLE LENGTH:21 days; COURSE: 3 to 6 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
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,Edward E [2435061]
6/6/2017 5:12:55 PM Page 28 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
mesna (MESNEX) 800 mg in sodium chloride 0.9 % 50 mL bag
800 mg (400 mg/m2 × 2 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) 2,400 mg in sodium chloride 0.9 % 250 mL bag
2,400 mg (1,200 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 5 – Planned for 8/31/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical Cancer (Advanced), Vulvar, Vaginal (Advanced) and Uterine Sarcoma (Adjuvant/Advanced); THERAPY: mesna
400 mg/m2 IV prior to start of ifosfomide Day 1 through 5; ifosfamide 1200 mg/m2 IV on Day 1 through 5; mesna 400 mg/m2 by
mouth 4 hours and 8 hours after the start of ifosfamide; CYCLE LENGTH:21 days; COURSE: 3 to 6 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
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.
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Zztestonc,Edward E [2435061]
6/6/2017 5:12:55 PM Page 29 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
mesna (MESNEX) 800 mg in sodium chloride 0.9 % 50 mL bag
800 mg (400 mg/m2 × 2 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) 2,400 mg in sodium chloride 0.9 % 250 mL bag
2,400 mg (1,200 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 4, Cycle 5 – Planned for 9/1/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical Cancer (Advanced), Vulvar, Vaginal (Advanced) and Uterine Sarcoma (Adjuvant/Advanced); THERAPY: mesna
400 mg/m2 IV prior to start of ifosfomide Day 1 through 5; ifosfamide 1200 mg/m2 IV on Day 1 through 5; mesna 400 mg/m2 by
mouth 4 hours and 8 hours after the start of ifosfamide; CYCLE LENGTH:21 days; COURSE: 3 to 6 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
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
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Zztestonc,Edward E [2435061]
6/6/2017 5:12:55 PM Page 30 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
mesna (MESNEX) 800 mg in sodium chloride 0.9 % 50 mL bag
800 mg (400 mg/m2 × 2 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) 2,400 mg in sodium chloride 0.9 % 250 mL bag
2,400 mg (1,200 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 5 – Planned for 9/2/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical Cancer (Advanced), Vulvar, Vaginal (Advanced) and Uterine Sarcoma (Adjuvant/Advanced); THERAPY: mesna
400 mg/m2 IV prior to start of ifosfomide Day 1 through 5; ifosfamide 1200 mg/m2 IV on Day 1 through 5; mesna 400 mg/m2 by
mouth 4 hours and 8 hours after the start of ifosfamide; CYCLE LENGTH:21 days; COURSE: 3 to 6 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
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,Edward E [2435061]
6/6/2017 5:12:55 PM Page 31 of 39
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
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
mesna (MESNEX) 800 mg in sodium chloride 0.9 % 50 mL bag
800 mg (400 mg/m2 × 2 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) 2,400 mg in sodium chloride 0.9 % 250 mL bag
2,400 mg (1,200 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 10 - Lab Only, Cycle 5 – Planned for 9/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical Cancer (Advanced), Vulvar, Vaginal (Advanced) and Uterine Sarcoma (Adjuvant/Advanced); THERAPY: mesna
400 mg/m2 IV prior to start of ifosfomide Day 1 through 5; ifosfamide 1200 mg/m2 IV on Day 1 through 5; mesna 400 mg/m2 by
mouth 4 hours and 8 hours after the start of ifosfamide; CYCLE LENGTH:21 days; COURSE: 3 to 6 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 6 – 9/19/2017 through 10/9/2017 (21 days), Planned
Day 1, Cycle 6 – Planned for 9/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical Cancer (Advanced), Vulvar, Vaginal (Advanced) and Uterine Sarcoma (Adjuvant/Advanced); THERAPY: mesna
400 mg/m2 IV prior to start of ifosfomide Day 1 through 5; ifosfamide 1200 mg/m2 IV on Day 1 through 5; mesna 400 mg/m2 by
mouth 4 hours and 8 hours after the start of ifosfamide; CYCLE LENGTH:21 days; COURSE: 3 to 6 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
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Zztestonc,Edward E [2435061]
6/6/2017 5:12:55 PM Page 32 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+17 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+17 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+17 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+17 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+17 Approximate, Expires-S+365, Routine
BUN
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
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: CBC, ANC, Urine Heme, Creatinine
Monitoring Parameters (1)
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Urine
Hemoglobin greater than Trace or Creatinine greater than upper limits of normal.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
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Zztestonc,Edward E [2435061]
6/6/2017 5:12:55 PM Page 33 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Treatment Medications
mesna (MESNEX) 800 mg in sodium chloride 0.9 % 50 mL bag
800 mg (400 mg/m2 × 2 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) 2,400 mg in sodium chloride 0.9 % 250 mL bag
2,400 mg (1,200 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Take Home Medications
mesna (MESNEX) 400 MG tab
Take 2 tabs by mouth 2 times daily. Take 4 hours and 8 hours after the start of ifosfamide on Day 1 through 5 for 10 doses., 800
mg (400 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
Follow-Up
DAY 2 FOLLOW-UP
LABS: Urinalysis - no microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide and mesna for 200 minutes.
DAY 3 FOLLOW-UP
LABS: Urinalysis - no microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide and mesna for 200 minutes.
DAY 4 FOLLOW-UP
LABS: Urinalysis - no microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide and mesna for 200 minutes.
DAY 5 FOLLOW-UP
LABS: Urinalysis - no microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide and mesna for 200 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 to be done locally), Electrolytes,
Magnesium, Glucose, BUN, Creatinine, Urinalysis - no microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide and
mesna for 200 minutes.
Day 2, Cycle 6 – Planned for 9/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical Cancer (Advanced), Vulvar, Vaginal (Advanced) and Uterine Sarcoma (Adjuvant/Advanced); THERAPY: mesna
400 mg/m2 IV prior to start of ifosfomide Day 1 through 5; ifosfamide 1200 mg/m2 IV on Day 1 through 5; mesna 400 mg/m2 by
mouth 4 hours and 8 hours after the start of ifosfamide; CYCLE LENGTH:21 days; COURSE: 3 to 6 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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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Zztestonc,Edward E [2435061]
6/6/2017 5:12:55 PM Page 34 of 39
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
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
mesna (MESNEX) 800 mg in sodium chloride 0.9 % 50 mL bag
800 mg (400 mg/m2 × 2 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) 2,400 mg in sodium chloride 0.9 % 250 mL bag
2,400 mg (1,200 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 6 – Planned for 9/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical Cancer (Advanced), Vulvar, Vaginal (Advanced) and Uterine Sarcoma (Adjuvant/Advanced); THERAPY: mesna
400 mg/m2 IV prior to start of ifosfomide Day 1 through 5; ifosfamide 1200 mg/m2 IV on Day 1 through 5; mesna 400 mg/m2 by
mouth 4 hours and 8 hours after the start of ifosfamide; CYCLE LENGTH:21 days; COURSE: 3 to 6 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
Flush Venous Access Device per Guidelines
Order details
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Zztestonc,Edward E [2435061]
6/6/2017 5:12:55 PM Page 35 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
mesna (MESNEX) 800 mg in sodium chloride 0.9 % 50 mL bag
800 mg (400 mg/m2 × 2 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) 2,400 mg in sodium chloride 0.9 % 250 mL bag
2,400 mg (1,200 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 4, Cycle 6 – Planned for 9/22/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical Cancer (Advanced), Vulvar, Vaginal (Advanced) and Uterine Sarcoma (Adjuvant/Advanced); THERAPY: mesna
400 mg/m2 IV prior to start of ifosfomide Day 1 through 5; ifosfamide 1200 mg/m2 IV on Day 1 through 5; mesna 400 mg/m2 by
mouth 4 hours and 8 hours after the start of ifosfamide; CYCLE LENGTH:21 days; COURSE: 3 to 6 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
Flush Venous Access Device per Guidelines
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Zztestonc,Edward E [2435061]
6/6/2017 5:12:55 PM Page 36 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
mesna (MESNEX) 800 mg in sodium chloride 0.9 % 50 mL bag
800 mg (400 mg/m2 × 2 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) 2,400 mg in sodium chloride 0.9 % 250 mL bag
2,400 mg (1,200 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 6 – Planned for 9/23/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical Cancer (Advanced), Vulvar, Vaginal (Advanced) and Uterine Sarcoma (Adjuvant/Advanced); THERAPY: mesna
400 mg/m2 IV prior to start of ifosfomide Day 1 through 5; ifosfamide 1200 mg/m2 IV on Day 1 through 5; mesna 400 mg/m2 by
mouth 4 hours and 8 hours after the start of ifosfamide; CYCLE LENGTH:21 days; COURSE: 3 to 6 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
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Zztestonc,Edward E [2435061]
6/6/2017 5:12:55 PM Page 37 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
mesna (MESNEX) 800 mg in sodium chloride 0.9 % 50 mL bag
800 mg (400 mg/m2 × 2 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) 2,400 mg in sodium chloride 0.9 % 250 mL bag
2,400 mg (1,200 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 10 - Lab Only, Cycle 6 – Planned for 9/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cervical Cancer (Advanced), Vulvar, Vaginal (Advanced) and Uterine Sarcoma (Adjuvant/Advanced); THERAPY: mesna
400 mg/m2 IV prior to start of ifosfomide Day 1 through 5; ifosfamide 1200 mg/m2 IV on Day 1 through 5; mesna 400 mg/m2 by
mouth 4 hours and 8 hours after the start of ifosfamide; CYCLE LENGTH:21 days; COURSE: 3 to 6 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,Edward E [2435061]
6/6/2017 5:12:55 PM Page 38 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Zztestonc,Edward E [2435061]
6/6/2017 5:12:55 PM Page 39 of 39
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org