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/clinical/cckm-tools/content/beacon-protocols/gyn/name-96771-en.cckm

201706157

page

100

UWHC,UWMF,

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

CSC GYN OUTPT Ifosfamide(21D:1,2,3) Paclitaxel(21D:1) VER 1-11-17 (HL 2272)

CSC GYN OUTPT Ifosfamide(21D:1,2,3) Paclitaxel(21D:1) VER 1-11-17 (HL 2272) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GYN


CSC GYN-OUTPT IFOSFAMIDE(21D:1,2,3)/PACLITAXEL(21D:1) 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: Uterine Sarcoma (Adjuvant or Advanced); THERAPY: PACLItaxel 135 mg/m2 IV Day 1, ifosfamide 1600 mg/m2 IV Day
1, 2 and 3 (1200 mg/m2 if prior irradiation), mesna 667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of
ifosfamide Day 1, 2 and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 8 cycles or until disease
progression or toxicity; NOTE: mesna dose must be adjusted if ifosfamide dose is reduced (total reduced mesna dose = total
reduced ifosfamide dose)
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Normal, Routine
ALBUMIN
Expected-S Approximate, Expires-S+365, Normal, Routine
URINALYSIS WITH MICROSCOPY
Expected-S Approximate, Expires-S+365, Normal, Routine
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
Take 5 tabs 12&6 hrs prior to 1st PACLItaxel dose, 3 tabs 12&6 hrs prior to 2nd dose, 2 tabs 12&6 hrs prior to 3rd dose, Disp-20
tab, R-0, starting S
prochlorperazine (COMPAZINE) 10 MG tab
Take 1 tab by mouth every 6 hours as needed for nausea/vomiting., 10 mg, Disp-30 tab, R-5, EVERY 6 HOURS PRN starting S,
Local Printer
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth twice daily X 2 days after ifosfamide then 1 tab every 8h as needed for nausea., Disp-30 tab, R-5, starting S
Take Home Medications (delete all that do not apply)
TBO-filgrastim (GRANIX) 300 MCG/0.5ML soln prefilled syringe
Inject 300 mcg under skin one time daily in evening. Begin Day 4 and continue until ANC is greater than 1000., 300 mcg, Disp-10
Syringe, R-5, 1 X DAILY (PM) starting S, Local Printer
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
TBO-filgrastim (GRANIX) 480 MCG/0.8ML soln prefilled syringe
Inject 480 mcg under skin one time daily in evening. Begin Day 4 and continue until ANC is greater than 1000., 480 mcg, Disp-10
Syringe, R-5, 1 X DAILY (PM) starting S, Local Printer
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
Cycle 1 – 6/6/2017 through 6/26/2017 (21 days), Planned
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Zztestonc,Edward E [2435061]
6/6/2017 5:53:11 PM Page 1 of 32
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Day 1, Cycle 1 – Planned for 6/6/2017
Treatment Plan Information
Reference Information (1)
UTERINE SARCOMA: Homesley H, et al. J Clin Oncol. 2007;25(5):526-31.
Treatment Plan Summary
DISEASE: Uterine Sarcoma (Adjuvant or Advanced); THERAPY: PACLItaxel 135 mg/m2 IV Day 1, ifosfamide 1600 mg/m2 IV Day
1, 2 and 3 (1200 mg/m2 if prior irradiation), mesna 667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of
ifosfamide Day 1, 2 and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 8 cycles or until disease
progression or toxicity; NOTE: mesna dose must be adjusted if ifosfamide dose is reduced (total reduced mesna dose = total
reduced ifosfamide dose)
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.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: ANC, Platelets, Creatinine, Total Bilirubin, AST, Albumin, Urinalysis
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1500/µL, Platelets less than 100K/µL, Creatinine greater than 2
mg/dL or Creatinine Clearance less than 50 mL/min, Total Bilirubin greater than 1.5 X ULN, AST greater than 3 X ULN, Albumin less
than 3 gm/dL or Urine Hemoglobin greater than Trace.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 18 mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
Monitoring Parameters (1)
Monitor for ifosfamide-related neurotoxicity (somnolence, agitation, confusion, delirium, hallucinations, incontinence, palsy, diplopia
or aphasia). Stop infusion and contact physician if toxicity is suspected.
Monitoring Parameters (2)
Monitor and notify physician for signs and symptoms of hemorrhagic cystitis (dysuria).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
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Zztestonc,Edward E [2435061]
6/6/2017 5:53:11 PM Page 2 of 32
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN Starting when released Until Discontinued, If PO not taken at home.
For use in patients who did not take dexamethasone at home.
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Give 30 minutes prior to PACLItaxel.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Give 30 minutes prior to PACLItaxel.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 270 mg in dextrose 5 % 500 mL non-PVC bag
270 mg (135 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Infuse over 180 minutes through non-PVC tubing and 0.2 or 0.22 micron in-line
filter during administration.
mesna (MESNEX) 1,334 mg in sodium chloride 0.9 % 50 mL bag
1,334 mg (667 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give 15 minutes prior to ifosfamide. Mesna dose must be adjusted if ifosfamide dose is reduced (total mesna dose = total ifosfamide
dose).
ifosfamide (IFEX) 3,200 mg in sodium chloride 0.9 % 250 mL bag
3,200 mg (1,600 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Dose = 1200 mg/m2 if patient has received prior irradiation.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): mesna
Take Home Medications
mesna (MESNEX) 400 MG tab
Take 3.5 tabs by mouth 2 times daily. Take 4 & 8 hours after start of ifosfamide on Day 1, 2, & 3, 1,400 mg (rounded from 1,334
mg = 667 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S, Local Printer
Mesna dose must be adjusted if ifosfamide dose is reduced (total mesna dose = total ifosfamide dose). Round dose to nearest 200
mg.
Follow-Up
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Zztestonc,Edward E [2435061]
6/6/2017 5:53:11 PM Page 3 of 32
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

MULTIPLE DAY FOLLOW-UP (1)
Day 2 and 3: LABS: Urinalysis with Microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide for 120 minutes
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be drawn locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be drawn locally), Creatinine,
Total Bilirubin, AST, Albumin, Urinalysis with Microscopy; CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel and ifosfamide
for 300 minutes
Day 2, Cycle 1 – Planned for 6/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Uterine Sarcoma (Adjuvant or Advanced); THERAPY: PACLItaxel 135 mg/m2 IV Day 1, ifosfamide 1600 mg/m2 IV Day
1, 2 and 3 (1200 mg/m2 if prior irradiation), mesna 667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of
ifosfamide Day 1, 2 and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 8 cycles or until disease
progression or toxicity; NOTE: mesna dose must be adjusted if ifosfamide dose is reduced (total reduced mesna dose = total
reduced ifosfamide dose)
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 WITH MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Urinalysis with Microscopy
Treatment Parameters
Hold treatment 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
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
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Zztestonc,Edward E [2435061]
6/6/2017 5:53:11 PM Page 4 of 32
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

10 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
mesna (MESNEX) 1,334 mg in sodium chloride 0.9 % 50 mL bag
1,334 mg (667 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give 15 minutes prior to ifosfamide. Mesna dose must be adjusted if ifosfamide dose is reduced (total mesna dose = total ifosfamide
dose).
ifosfamide (IFEX) 3,200 mg in sodium chloride 0.9 % 250 mL bag
3,200 mg (1,600 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Dose = 1200 mg/m2 if patient has received prior irradiation.
See Take Home Medication(s)
Refer to the take home medications section on Day 1 for the following treatment medication(s): mesna
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: Uterine Sarcoma (Adjuvant or Advanced); THERAPY: PACLItaxel 135 mg/m2 IV Day 1, ifosfamide 1600 mg/m2 IV Day
1, 2 and 3 (1200 mg/m2 if prior irradiation), mesna 667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of
ifosfamide Day 1, 2 and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 8 cycles or until disease
progression or toxicity; NOTE: mesna dose must be adjusted if ifosfamide dose is reduced (total reduced mesna dose = total
reduced ifosfamide dose)
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 WITH MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Urinalysis with Microscopy
Treatment Parameters
Hold treatment 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 5:53:11 PM Page 5 of 32
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
mesna (MESNEX) 1,334 mg in sodium chloride 0.9 % 50 mL bag
1,334 mg (667 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give 15 minutes prior to ifosfamide. Mesna dose must be adjusted if ifosfamide dose is reduced (total mesna dose = total ifosfamide
dose).
ifosfamide (IFEX) 3,200 mg in sodium chloride 0.9 % 250 mL bag
3,200 mg (1,600 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Dose = 1200 mg/m2 if patient has received prior irradiation.
See Take Home Medication(s)
Refer to the take home medications section on Day 1 for the following treatment medication(s): mesna
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: Uterine Sarcoma (Adjuvant or Advanced); THERAPY: PACLItaxel 135 mg/m2 IV Day 1, ifosfamide 1600 mg/m2 IV Day
1, 2 and 3 (1200 mg/m2 if prior irradiation), mesna 667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of
ifosfamide Day 1, 2 and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 8 cycles or until disease
progression or toxicity; NOTE: mesna dose must be adjusted if ifosfamide dose is reduced (total reduced mesna dose = total
reduced ifosfamide dose)
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+7 Approximate, Expires-S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Normal, 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
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Zztestonc,Edward E [2435061]
6/6/2017 5:53:11 PM Page 6 of 32
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

DISEASE: Uterine Sarcoma (Adjuvant or Advanced); THERAPY: PACLItaxel 135 mg/m2 IV Day 1, ifosfamide 1600 mg/m2 IV Day
1, 2 and 3 (1200 mg/m2 if prior irradiation), mesna 667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of
ifosfamide Day 1, 2 and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 8 cycles or until disease
progression or toxicity; NOTE: mesna dose must be adjusted if ifosfamide dose is reduced (total reduced mesna dose = total
reduced ifosfamide dose)
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+19 Approximate, Expires-S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
ALBUMIN
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
URINALYSIS WITH MICROSCOPY
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: ANC, Platelets, Creatinine, Total Bilirubin, AST, Albumin, Urinalysis
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1500/µL, Platelets less than 100K/µL, Creatinine greater than 2
mg/dL or Creatinine Clearance less than 50 mL/min, Total Bilirubin greater than 1.5 X ULN, AST greater than 3 X ULN, Albumin less
than 3 gm/dL or Urine Hemoglobin greater than Trace.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 18 mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
Monitoring Parameters (1)
Monitor for ifosfamide-related neurotoxicity (somnolence, agitation, confusion, delirium, hallucinations, incontinence, palsy, diplopia
or aphasia). Stop infusion and contact physician if toxicity is suspected.
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Zztestonc,Edward E [2435061]
6/6/2017 5:53:11 PM Page 7 of 32
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Monitoring Parameters (2)
Monitor and notify physician for signs and symptoms of hemorrhagic cystitis (dysuria).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Give 30 minutes prior to PACLItaxel.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Give 30 minutes prior to PACLItaxel.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, PRN - NOTIFY PHARMACY WHEN NEEDED Starting when released Until Discontinued, If PO not taken at
home.
For use in patients who did not take dexamethasone at home. Notify pharmacy that medication is needed
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 270 mg in dextrose 5 % 500 mL non-PVC bag
270 mg (135 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Infuse over 180 minutes through non-PVC tubing and 0.2 or 0.22 micron in-line
filter during administration.
mesna (MESNEX) 1,334 mg in sodium chloride 0.9 % 50 mL bag
1,334 mg (667 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give 15 minutes prior to ifosfamide. Mesna dose must be adjusted if ifosfamide dose is reduced (total mesna dose = total ifosfamide
dose).
ifosfamide (IFEX) 3,200 mg in sodium chloride 0.9 % 250 mL bag
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Zztestonc,Edward E [2435061]
6/6/2017 5:53:11 PM Page 8 of 32
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

3,200 mg (1,600 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Dose = 1200 mg/m2 if patient has received prior irradiation.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): mesna
Take Home Medications
mesna (MESNEX) 400 MG tab
Take 3.5 tabs by mouth 2 times daily. Take 4 & 8 hours after start of ifosfamide on Day 1, 2, & 3, 1,400 mg (rounded from 1,334
mg = 667 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
Mesna dose must be adjusted if ifosfamide dose is reduced (total mesna dose = total ifosfamide dose). Round dose to nearest 200
mg.
Follow-Up
MULTIPLE DAY FOLLOW-UP (1)
Day 2 and 3: LABS: Urinalysis with Microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide for 120 minutes
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be drawn locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be drawn locally), Creatinine,
Total Bilirubin, AST, Albumin, Urinalysis with Microscopy; CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel and ifosfamide
for 300 minutes
Day 2, Cycle 2 – Planned for 6/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Uterine Sarcoma (Adjuvant or Advanced); THERAPY: PACLItaxel 135 mg/m2 IV Day 1, ifosfamide 1600 mg/m2 IV Day
1, 2 and 3 (1200 mg/m2 if prior irradiation), mesna 667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of
ifosfamide Day 1, 2 and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 8 cycles or until disease
progression or toxicity; NOTE: mesna dose must be adjusted if ifosfamide dose is reduced (total reduced mesna dose = total
reduced ifosfamide dose)
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 WITH MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Urinalysis with Microscopy
Treatment Parameters
Hold treatment 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
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Zztestonc,Edward E [2435061]
6/6/2017 5:53:11 PM Page 9 of 32
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
mesna (MESNEX) 1,334 mg in sodium chloride 0.9 % 50 mL bag
1,334 mg (667 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give 15 minutes prior to ifosfamide. Mesna dose must be adjusted if ifosfamide dose is reduced (total mesna dose = total ifosfamide
dose).
ifosfamide (IFEX) 3,200 mg in sodium chloride 0.9 % 250 mL bag
3,200 mg (1,600 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Dose = 1200 mg/m2 if patient has received prior irradiation.
See Take Home Medication(s)
Refer to the take home medications section on Day 1 for the following treatment medication(s): mesna
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: Uterine Sarcoma (Adjuvant or Advanced); THERAPY: PACLItaxel 135 mg/m2 IV Day 1, ifosfamide 1600 mg/m2 IV Day
1, 2 and 3 (1200 mg/m2 if prior irradiation), mesna 667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of
ifosfamide Day 1, 2 and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 8 cycles or until disease
progression or toxicity; NOTE: mesna dose must be adjusted if ifosfamide dose is reduced (total reduced mesna dose = total
reduced ifosfamide dose)
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 WITH MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Urinalysis with Microscopy
Treatment Parameters
Hold treatment 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 5:53:11 PM Page 10 of 32
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
mesna (MESNEX) 1,334 mg in sodium chloride 0.9 % 50 mL bag
1,334 mg (667 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give 15 minutes prior to ifosfamide. Mesna dose must be adjusted if ifosfamide dose is reduced (total mesna dose = total ifosfamide
dose).
ifosfamide (IFEX) 3,200 mg in sodium chloride 0.9 % 250 mL bag
3,200 mg (1,600 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Dose = 1200 mg/m2 if patient has received prior irradiation.
See Take Home Medication(s)
Refer to the take home medications section on Day 1 for the following treatment medication(s): mesna
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: Uterine Sarcoma (Adjuvant or Advanced); THERAPY: PACLItaxel 135 mg/m2 IV Day 1, ifosfamide 1600 mg/m2 IV Day
1, 2 and 3 (1200 mg/m2 if prior irradiation), mesna 667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of
ifosfamide Day 1, 2 and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 8 cycles or until disease
progression or toxicity; NOTE: mesna dose must be adjusted if ifosfamide dose is reduced (total reduced mesna dose = total
reduced ifosfamide dose)
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+7 Approximate, Expires-S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
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Zztestonc,Edward E [2435061]
6/6/2017 5:53:11 PM Page 11 of 32
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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: Uterine Sarcoma (Adjuvant or Advanced); THERAPY: PACLItaxel 135 mg/m2 IV Day 1, ifosfamide 1600 mg/m2 IV Day
1, 2 and 3 (1200 mg/m2 if prior irradiation), mesna 667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of
ifosfamide Day 1, 2 and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 8 cycles or until disease
progression or toxicity; NOTE: mesna dose must be adjusted if ifosfamide dose is reduced (total reduced mesna dose = total
reduced ifosfamide dose)
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+19 Approximate, Expires-S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
ALBUMIN
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
URINALYSIS WITH MICROSCOPY
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: ANC, Platelets, Creatinine, Total Bilirubin, AST, Albumin, Urinalysis
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1500/µL, Platelets less than 100K/µL, Creatinine greater than 2
mg/dL or Creatinine Clearance less than 50 mL/min, Total Bilirubin greater than 1.5 X ULN, AST greater than 3 X ULN, Albumin less
than 3 gm/dL or Urine Hemoglobin greater than Trace.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
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Zztestonc,Edward E [2435061]
6/6/2017 5:53:11 PM Page 12 of 32
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 18 mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
Monitoring Parameters (1)
Monitor for ifosfamide-related neurotoxicity (somnolence, agitation, confusion, delirium, hallucinations, incontinence, palsy, diplopia
or aphasia). Stop infusion and contact physician if toxicity is suspected.
Monitoring Parameters (2)
Monitor and notify physician for signs and symptoms of hemorrhagic cystitis (dysuria).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Give 30 minutes prior to PACLItaxel.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Give 30 minutes prior to PACLItaxel.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, PRN - NOTIFY PHARMACY WHEN NEEDED Starting when released Until Discontinued, If PO not taken at
home.
For use in patients who did not take dexamethasone at home. Notify pharmacy that medication is needed
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
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Zztestonc,Edward E [2435061]
6/6/2017 5:53:11 PM Page 13 of 32
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 270 mg in dextrose 5 % 500 mL non-PVC bag
270 mg (135 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Infuse over 180 minutes through non-PVC tubing and 0.2 or 0.22 micron in-line
filter during administration.
mesna (MESNEX) 1,334 mg in sodium chloride 0.9 % 50 mL bag
1,334 mg (667 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give 15 minutes prior to ifosfamide. Mesna dose must be adjusted if ifosfamide dose is reduced (total mesna dose = total ifosfamide
dose).
ifosfamide (IFEX) 3,200 mg in sodium chloride 0.9 % 250 mL bag
3,200 mg (1,600 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Dose = 1200 mg/m2 if patient has received prior irradiation.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): mesna
Take Home Medications
mesna (MESNEX) 400 MG tab
Take 3.5 tabs by mouth 2 times daily. Take 4 & 8 hours after start of ifosfamide on Day 1, 2, & 3, 1,400 mg (rounded from 1,334
mg = 667 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
Mesna dose must be adjusted if ifosfamide dose is reduced (total mesna dose = total ifosfamide dose). Round dose to nearest 200
mg.
Follow-Up
MULTIPLE DAY FOLLOW-UP (1)
Day 2 and 3: LABS: Urinalysis with Microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide for 120 minutes
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be drawn locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be drawn locally), Creatinine,
Total Bilirubin, AST, Albumin, Urinalysis with Microscopy; CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel and ifosfamide
for 300 minutes
Day 2, Cycle 3 – Planned for 7/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Uterine Sarcoma (Adjuvant or Advanced); THERAPY: PACLItaxel 135 mg/m2 IV Day 1, ifosfamide 1600 mg/m2 IV Day
1, 2 and 3 (1200 mg/m2 if prior irradiation), mesna 667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of
ifosfamide Day 1, 2 and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 8 cycles or until disease
progression or toxicity; NOTE: mesna dose must be adjusted if ifosfamide dose is reduced (total reduced mesna dose = total
reduced ifosfamide dose)
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 WITH MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Urinalysis with Microscopy
Treatment Parameters
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Zztestonc,Edward E [2435061]
6/6/2017 5:53:11 PM Page 14 of 32
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Hold treatment 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
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
mesna (MESNEX) 1,334 mg in sodium chloride 0.9 % 50 mL bag
1,334 mg (667 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give 15 minutes prior to ifosfamide. Mesna dose must be adjusted if ifosfamide dose is reduced (total mesna dose = total ifosfamide
dose).
ifosfamide (IFEX) 3,200 mg in sodium chloride 0.9 % 250 mL bag
3,200 mg (1,600 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Dose = 1200 mg/m2 if patient has received prior irradiation.
See Take Home Medication(s)
Refer to the take home medications section on Day 1 for the following treatment medication(s): mesna
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: Uterine Sarcoma (Adjuvant or Advanced); THERAPY: PACLItaxel 135 mg/m2 IV Day 1, ifosfamide 1600 mg/m2 IV Day
1, 2 and 3 (1200 mg/m2 if prior irradiation), mesna 667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of
ifosfamide Day 1, 2 and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 8 cycles or until disease
progression or toxicity; NOTE: mesna dose must be adjusted if ifosfamide dose is reduced (total reduced mesna dose = total
reduced ifosfamide dose)
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 5:53:11 PM Page 15 of 32
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

URINALYSIS WITH MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Urinalysis with Microscopy
Treatment Parameters
Hold treatment 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
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
mesna (MESNEX) 1,334 mg in sodium chloride 0.9 % 50 mL bag
1,334 mg (667 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give 15 minutes prior to ifosfamide. Mesna dose must be adjusted if ifosfamide dose is reduced (total mesna dose = total ifosfamide
dose).
ifosfamide (IFEX) 3,200 mg in sodium chloride 0.9 % 250 mL bag
3,200 mg (1,600 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Dose = 1200 mg/m2 if patient has received prior irradiation.
See Take Home Medication(s)
Refer to the take home medications section on Day 1 for the following treatment medication(s): mesna
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: Uterine Sarcoma (Adjuvant or Advanced); THERAPY: PACLItaxel 135 mg/m2 IV Day 1, ifosfamide 1600 mg/m2 IV Day
1, 2 and 3 (1200 mg/m2 if prior irradiation), mesna 667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of
ifosfamide Day 1, 2 and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 8 cycles or until disease
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Zztestonc,Edward E [2435061]
6/6/2017 5:53:11 PM Page 16 of 32
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

progression or toxicity; NOTE: mesna dose must be adjusted if ifosfamide dose is reduced (total reduced mesna dose = total
reduced ifosfamide dose)
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+7 Approximate, Expires-S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Normal, 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: Uterine Sarcoma (Adjuvant or Advanced); THERAPY: PACLItaxel 135 mg/m2 IV Day 1, ifosfamide 1600 mg/m2 IV Day
1, 2 and 3 (1200 mg/m2 if prior irradiation), mesna 667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of
ifosfamide Day 1, 2 and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 8 cycles or until disease
progression or toxicity; NOTE: mesna dose must be adjusted if ifosfamide dose is reduced (total reduced mesna dose = total
reduced ifosfamide dose)
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+19 Approximate, Expires-S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
ALBUMIN
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
URINALYSIS WITH MICROSCOPY
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
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Zztestonc,Edward E [2435061]
6/6/2017 5:53:11 PM Page 17 of 32
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Verify Labs
Verify pretreatment labs have been obtained: ANC, Platelets, Creatinine, Total Bilirubin, AST, Albumin, Urinalysis
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1500/µL, Platelets less than 100K/µL, Creatinine greater than 2
mg/dL or Creatinine Clearance less than 50 mL/min, Total Bilirubin greater than 1.5 X ULN, AST greater than 3 X ULN, Albumin less
than 3 gm/dL or Urine Hemoglobin greater than Trace.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 18 mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
Monitoring Parameters (1)
Monitor for ifosfamide-related neurotoxicity (somnolence, agitation, confusion, delirium, hallucinations, incontinence, palsy, diplopia
or aphasia). Stop infusion and contact physician if toxicity is suspected.
Monitoring Parameters (2)
Monitor and notify physician for signs and symptoms of hemorrhagic cystitis (dysuria).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Give 30 minutes prior to PACLItaxel.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Give 30 minutes prior to PACLItaxel.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
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Zztestonc,Edward E [2435061]
6/6/2017 5:53:11 PM Page 18 of 32
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 270 mg in dextrose 5 % 500 mL non-PVC bag
270 mg (135 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Infuse over 180 minutes through non-PVC tubing and 0.2 or 0.22 micron in-line
filter during administration.
mesna (MESNEX) 1,334 mg in sodium chloride 0.9 % 50 mL bag
1,334 mg (667 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give 15 minutes prior to ifosfamide. Mesna dose must be adjusted if ifosfamide dose is reduced (total mesna dose = total ifosfamide
dose).
ifosfamide (IFEX) 3,200 mg in sodium chloride 0.9 % 250 mL bag
3,200 mg (1,600 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Dose = 1200 mg/m2 if patient has received prior irradiation.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): mesna
Take Home Medications
mesna (MESNEX) 400 MG tab
Take 3.5 tabs by mouth 2 times daily. Take 4 & 8 hours after start of ifosfamide on Day 1, 2, & 3, 1,400 mg (rounded from 1,334
mg = 667 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
Mesna dose must be adjusted if ifosfamide dose is reduced (total mesna dose = total ifosfamide dose). Round dose to nearest 200
mg.
Follow-Up
MULTIPLE DAY FOLLOW-UP (1)
Day 2 and 3: LABS: Urinalysis with Microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide for 120 minutes
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be drawn locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be drawn locally), Creatinine,
Total Bilirubin, AST, Albumin, Urinalysis with Microscopy; CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel and ifosfamide
for 300 minutes
Day 2, Cycle 4 – Planned for 8/9/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Uterine Sarcoma (Adjuvant or Advanced); THERAPY: PACLItaxel 135 mg/m2 IV Day 1, ifosfamide 1600 mg/m2 IV Day
1, 2 and 3 (1200 mg/m2 if prior irradiation), mesna 667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of
ifosfamide Day 1, 2 and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 8 cycles or until disease
progression or toxicity; NOTE: mesna dose must be adjusted if ifosfamide dose is reduced (total reduced mesna dose = total
reduced ifosfamide dose)
IV Access
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Zztestonc,Edward E [2435061]
6/6/2017 5:53:11 PM Page 19 of 32
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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 WITH MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Urinalysis with Microscopy
Treatment Parameters
Hold treatment 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
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
mesna (MESNEX) 1,334 mg in sodium chloride 0.9 % 50 mL bag
1,334 mg (667 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give 15 minutes prior to ifosfamide. Mesna dose must be adjusted if ifosfamide dose is reduced (total mesna dose = total ifosfamide
dose).
ifosfamide (IFEX) 3,200 mg in sodium chloride 0.9 % 250 mL bag
3,200 mg (1,600 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Dose = 1200 mg/m2 if patient has received prior irradiation.
See Take Home Medication(s)
Refer to the take home medications section on Day 1 for the following treatment medication(s): mesna
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 4 – Planned for 8/10/2017
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Zztestonc,Edward E [2435061]
6/6/2017 5:53:11 PM Page 20 of 32
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Uterine Sarcoma (Adjuvant or Advanced); THERAPY: PACLItaxel 135 mg/m2 IV Day 1, ifosfamide 1600 mg/m2 IV Day
1, 2 and 3 (1200 mg/m2 if prior irradiation), mesna 667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of
ifosfamide Day 1, 2 and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 8 cycles or until disease
progression or toxicity; NOTE: mesna dose must be adjusted if ifosfamide dose is reduced (total reduced mesna dose = total
reduced ifosfamide dose)
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 WITH MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Urinalysis with Microscopy
Treatment Parameters
Hold treatment 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
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
mesna (MESNEX) 1,334 mg in sodium chloride 0.9 % 50 mL bag
1,334 mg (667 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give 15 minutes prior to ifosfamide. Mesna dose must be adjusted if ifosfamide dose is reduced (total mesna dose = total ifosfamide
dose).
ifosfamide (IFEX) 3,200 mg in sodium chloride 0.9 % 250 mL bag
3,200 mg (1,600 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Dose = 1200 mg/m2 if patient has received prior irradiation.
See Take Home Medication(s)
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Zztestonc,Edward E [2435061]
6/6/2017 5:53:11 PM Page 21 of 32
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Refer to the take home medications section on Day 1 for the following treatment medication(s): mesna
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: Uterine Sarcoma (Adjuvant or Advanced); THERAPY: PACLItaxel 135 mg/m2 IV Day 1, ifosfamide 1600 mg/m2 IV Day
1, 2 and 3 (1200 mg/m2 if prior irradiation), mesna 667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of
ifosfamide Day 1, 2 and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 8 cycles or until disease
progression or toxicity; NOTE: mesna dose must be adjusted if ifosfamide dose is reduced (total reduced mesna dose = total
reduced ifosfamide dose)
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+7 Approximate, Expires-S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Normal, 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: Uterine Sarcoma (Adjuvant or Advanced); THERAPY: PACLItaxel 135 mg/m2 IV Day 1, ifosfamide 1600 mg/m2 IV Day
1, 2 and 3 (1200 mg/m2 if prior irradiation), mesna 667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of
ifosfamide Day 1, 2 and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 8 cycles or until disease
progression or toxicity; NOTE: mesna dose must be adjusted if ifosfamide dose is reduced (total reduced mesna dose = total
reduced ifosfamide dose)
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+19 Approximate, Expires-S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
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Zztestonc,Edward E [2435061]
6/6/2017 5:53:11 PM Page 22 of 32
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

CREATININE
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
ALBUMIN
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
URINALYSIS WITH MICROSCOPY
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: ANC, Platelets, Creatinine, Total Bilirubin, AST, Albumin, Urinalysis
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1500/µL, Platelets less than 100K/µL, Creatinine greater than 2
mg/dL or Creatinine Clearance less than 50 mL/min, Total Bilirubin greater than 1.5 X ULN, AST greater than 3 X ULN, Albumin less
than 3 gm/dL or Urine Hemoglobin greater than Trace.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 18 mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
Monitoring Parameters (1)
Monitor for ifosfamide-related neurotoxicity (somnolence, agitation, confusion, delirium, hallucinations, incontinence, palsy, diplopia
or aphasia). Stop infusion and contact physician if toxicity is suspected.
Monitoring Parameters (2)
Monitor and notify physician for signs and symptoms of hemorrhagic cystitis (dysuria).
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 5:53:11 PM Page 23 of 32
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Pre-Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Give 30 minutes prior to PACLItaxel.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Give 30 minutes prior to PACLItaxel.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 270 mg in dextrose 5 % 500 mL non-PVC bag
270 mg (135 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Infuse over 180 minutes through non-PVC tubing and 0.2 or 0.22 micron in-line
filter during administration.
mesna (MESNEX) 1,334 mg in sodium chloride 0.9 % 50 mL bag
1,334 mg (667 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give 15 minutes prior to ifosfamide. Mesna dose must be adjusted if ifosfamide dose is reduced (total mesna dose = total ifosfamide
dose).
ifosfamide (IFEX) 3,200 mg in sodium chloride 0.9 % 250 mL bag
3,200 mg (1,600 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Dose = 1200 mg/m2 if patient has received prior irradiation.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): mesna
Take Home Medications
mesna (MESNEX) 400 MG tab
Take 3.5 tabs by mouth 2 times daily. Take 4 & 8 hours after start of ifosfamide on Day 1, 2, & 3, 1,400 mg (rounded from 1,334
mg = 667 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
Mesna dose must be adjusted if ifosfamide dose is reduced (total mesna dose = total ifosfamide dose). Round dose to nearest 200
mg.
Follow-Up
MULTIPLE DAY FOLLOW-UP (1)
Day 2 and 3: LABS: Urinalysis with Microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide for 120 minutes
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be drawn locally)
DAY 22 FOLLOW-UP
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Zztestonc,Edward E [2435061]
6/6/2017 5:53:11 PM Page 24 of 32
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be drawn locally), Creatinine,
Total Bilirubin, AST, Albumin, Urinalysis with Microscopy; CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel and ifosfamide
for 300 minutes
Day 2, Cycle 5 – Planned for 8/30/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Uterine Sarcoma (Adjuvant or Advanced); THERAPY: PACLItaxel 135 mg/m2 IV Day 1, ifosfamide 1600 mg/m2 IV Day
1, 2 and 3 (1200 mg/m2 if prior irradiation), mesna 667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of
ifosfamide Day 1, 2 and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 8 cycles or until disease
progression or toxicity; NOTE: mesna dose must be adjusted if ifosfamide dose is reduced (total reduced mesna dose = total
reduced ifosfamide dose)
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 WITH MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Urinalysis with Microscopy
Treatment Parameters
Hold treatment 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
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
mesna (MESNEX) 1,334 mg in sodium chloride 0.9 % 50 mL bag
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Zztestonc,Edward E [2435061]
6/6/2017 5:53:11 PM Page 25 of 32
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

1,334 mg (667 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give 15 minutes prior to ifosfamide. Mesna dose must be adjusted if ifosfamide dose is reduced (total mesna dose = total ifosfamide
dose).
ifosfamide (IFEX) 3,200 mg in sodium chloride 0.9 % 250 mL bag
3,200 mg (1,600 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Dose = 1200 mg/m2 if patient has received prior irradiation.
See Take Home Medication(s)
Refer to the take home medications section on Day 1 for the following treatment medication(s): mesna
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: Uterine Sarcoma (Adjuvant or Advanced); THERAPY: PACLItaxel 135 mg/m2 IV Day 1, ifosfamide 1600 mg/m2 IV Day
1, 2 and 3 (1200 mg/m2 if prior irradiation), mesna 667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of
ifosfamide Day 1, 2 and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 8 cycles or until disease
progression or toxicity; NOTE: mesna dose must be adjusted if ifosfamide dose is reduced (total reduced mesna dose = total
reduced ifosfamide dose)
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 WITH MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Urinalysis with Microscopy
Treatment Parameters
Hold treatment 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 5:53:11 PM Page 26 of 32
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

16 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
mesna (MESNEX) 1,334 mg in sodium chloride 0.9 % 50 mL bag
1,334 mg (667 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give 15 minutes prior to ifosfamide. Mesna dose must be adjusted if ifosfamide dose is reduced (total mesna dose = total ifosfamide
dose).
ifosfamide (IFEX) 3,200 mg in sodium chloride 0.9 % 250 mL bag
3,200 mg (1,600 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Dose = 1200 mg/m2 if patient has received prior irradiation.
See Take Home Medication(s)
Refer to the take home medications section on Day 1 for the following treatment medication(s): mesna
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: Uterine Sarcoma (Adjuvant or Advanced); THERAPY: PACLItaxel 135 mg/m2 IV Day 1, ifosfamide 1600 mg/m2 IV Day
1, 2 and 3 (1200 mg/m2 if prior irradiation), mesna 667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of
ifosfamide Day 1, 2 and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 8 cycles or until disease
progression or toxicity; NOTE: mesna dose must be adjusted if ifosfamide dose is reduced (total reduced mesna dose = total
reduced ifosfamide dose)
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+7 Approximate, Expires-S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Normal, 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: Uterine Sarcoma (Adjuvant or Advanced); THERAPY: PACLItaxel 135 mg/m2 IV Day 1, ifosfamide 1600 mg/m2 IV Day
1, 2 and 3 (1200 mg/m2 if prior irradiation), mesna 667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of
ifosfamide Day 1, 2 and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 8 cycles or until disease
progression or toxicity; NOTE: mesna dose must be adjusted if ifosfamide dose is reduced (total reduced mesna dose = total
reduced ifosfamide dose)
Consent
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Zztestonc,Edward E [2435061]
6/6/2017 5:53:11 PM Page 27 of 32
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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+19 Approximate, Expires-S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
ALBUMIN
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
URINALYSIS WITH MICROSCOPY
Expected-S+19 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: ANC, Platelets, Creatinine, Total Bilirubin, AST, Albumin, Urinalysis
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1500/µL, Platelets less than 100K/µL, Creatinine greater than 2
mg/dL or Creatinine Clearance less than 50 mL/min, Total Bilirubin greater than 1.5 X ULN, AST greater than 3 X ULN, Albumin less
than 3 gm/dL or Urine Hemoglobin greater than Trace.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 18 mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
Monitoring Parameters (1)
Monitor for ifosfamide-related neurotoxicity (somnolence, agitation, confusion, delirium, hallucinations, incontinence, palsy, diplopia
or aphasia). Stop infusion and contact physician if toxicity is suspected.
Monitoring Parameters (2)
Monitor and notify physician for signs and symptoms of hemorrhagic cystitis (dysuria).
Flush Venous Access Device per Guidelines
Order details
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Zztestonc,Edward E [2435061]
6/6/2017 5:53:11 PM Page 28 of 32
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Give 30 minutes prior to PACLItaxel.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Give 30 minutes prior to PACLItaxel.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 270 mg in dextrose 5 % 500 mL non-PVC bag
270 mg (135 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Infuse over 180 minutes through non-PVC tubing and 0.2 or 0.22 micron in-line
filter during administration.
mesna (MESNEX) 1,334 mg in sodium chloride 0.9 % 50 mL bag
1,334 mg (667 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give 15 minutes prior to ifosfamide. Mesna dose must be adjusted if ifosfamide dose is reduced (total mesna dose = total ifosfamide
dose).
ifosfamide (IFEX) 3,200 mg in sodium chloride 0.9 % 250 mL bag
3,200 mg (1,600 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Dose = 1200 mg/m2 if patient has received prior irradiation.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): mesna
Take Home Medications
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Zztestonc,Edward E [2435061]
6/6/2017 5:53:11 PM Page 29 of 32
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

mesna (MESNEX) 400 MG tab
Take 3.5 tabs by mouth 2 times daily. Take 4 & 8 hours after start of ifosfamide on Day 1, 2, & 3, 1,400 mg (rounded from 1,334
mg = 667 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
Mesna dose must be adjusted if ifosfamide dose is reduced (total mesna dose = total ifosfamide dose). Round dose to nearest 200
mg.
Follow-Up
MULTIPLE DAY FOLLOW-UP (1)
Day 2 and 3: LABS: Urinalysis with Microscopy; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide for 120 minutes
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be drawn locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be drawn locally), Creatinine,
Total Bilirubin, AST, Albumin, Urinalysis with Microscopy; CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel and ifosfamide
for 300 minutes
Day 2, Cycle 6 – Planned for 9/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Uterine Sarcoma (Adjuvant or Advanced); THERAPY: PACLItaxel 135 mg/m2 IV Day 1, ifosfamide 1600 mg/m2 IV Day
1, 2 and 3 (1200 mg/m2 if prior irradiation), mesna 667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of
ifosfamide Day 1, 2 and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 8 cycles or until disease
progression or toxicity; NOTE: mesna dose must be adjusted if ifosfamide dose is reduced (total reduced mesna dose = total
reduced ifosfamide dose)
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 WITH MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Urinalysis with Microscopy
Treatment Parameters
Hold treatment 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 5:53:11 PM Page 30 of 32
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
mesna (MESNEX) 1,334 mg in sodium chloride 0.9 % 50 mL bag
1,334 mg (667 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give 15 minutes prior to ifosfamide. Mesna dose must be adjusted if ifosfamide dose is reduced (total mesna dose = total ifosfamide
dose).
ifosfamide (IFEX) 3,200 mg in sodium chloride 0.9 % 250 mL bag
3,200 mg (1,600 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Dose = 1200 mg/m2 if patient has received prior irradiation.
See Take Home Medication(s)
Refer to the take home medications section on Day 1 for the following treatment medication(s): mesna
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: Uterine Sarcoma (Adjuvant or Advanced); THERAPY: PACLItaxel 135 mg/m2 IV Day 1, ifosfamide 1600 mg/m2 IV Day
1, 2 and 3 (1200 mg/m2 if prior irradiation), mesna 667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of
ifosfamide Day 1, 2 and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 8 cycles or until disease
progression or toxicity; NOTE: mesna dose must be adjusted if ifosfamide dose is reduced (total reduced mesna dose = total
reduced ifosfamide dose)
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 WITH MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Urinalysis with Microscopy
Treatment Parameters
Hold treatment 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.
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Zztestonc,Edward E [2435061]
6/6/2017 5:53:11 PM Page 31 of 32
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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
Give prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
mesna (MESNEX) 1,334 mg in sodium chloride 0.9 % 50 mL bag
1,334 mg (667 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give 15 minutes prior to ifosfamide. Mesna dose must be adjusted if ifosfamide dose is reduced (total mesna dose = total ifosfamide
dose).
ifosfamide (IFEX) 3,200 mg in sodium chloride 0.9 % 250 mL bag
3,200 mg (1,600 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Dose = 1200 mg/m2 if patient has received prior irradiation.
See Take Home Medication(s)
Refer to the take home medications section on Day 1 for the following treatment medication(s): mesna
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: Uterine Sarcoma (Adjuvant or Advanced); THERAPY: PACLItaxel 135 mg/m2 IV Day 1, ifosfamide 1600 mg/m2 IV Day
1, 2 and 3 (1200 mg/m2 if prior irradiation), mesna 667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of
ifosfamide Day 1, 2 and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 8 cycles or until disease
progression or toxicity; NOTE: mesna dose must be adjusted if ifosfamide dose is reduced (total reduced mesna dose = total
reduced ifosfamide dose)
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+7 Approximate, Expires-S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Normal, 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 5:53:11 PM Page 32 of 32
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org