/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/beacon-protocols/,/clinical/cckm-tools/content/beacon-protocols/hem---lymphoma/,

/clinical/cckm-tools/content/beacon-protocols/hem---lymphoma/name-96865-en.cckm

201605136

page

100

UWHC,UWMF,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Beacon Protocols,Hem - Lymphoma

CSC Hem ICE Ver 2-2-16 (HL 1816)

CSC Hem ICE Ver 2-2-16 (HL 1816) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Lymphoma


CSC HEM ICE VER: 2-2-16 – Properties
Cycle 1 – 2/4/2016 through 2/17/2016 (14 days), Planned
Days 1 through 3 Inpatient , Cycle 1 – Planned for 2/4/2016 through 2/6/2016
Treatment Plan Information
Reference Information (1)
NON HODGKIN LYMPHOMA: Moskowitz CH et al. J Clin Oncol 1999;12:3776-85.
Reference Information (2)
HODGKIN LYMPHOMA: Moskowitz et al. Blood 2001:97(3), 616-23
Treatment Plan Summary
DISEASE: Non-Hodgkin Lymphoma and Hodgkin Lymphoma; THERAPY: etoposide 100 mg/m2/day IV
Day 1 through 3, ifosfamide 5 gm/m2 with mesna 5 gm/m2 IV continuous infusion over 24 hours Day 2, CARBOplatin
(AUC = 5) IV Day 2 (maximum dose = 800mg); CYCLE LENGTH: 14 to 21 days; COURSE: up to 4 cycles. GROWTH
FACTOR REQUIRED.
Note to All Staff (1)
Risk factors associated with ifosfamide neurotoxicity may include hypoalbuminemia, renal dysfunction
(Creatinine Clearance less than 60 mL/min), and prior history of ifosfamide-induced encephalopathy. Consider dose
reduction or methylene blue prophylaxis if present.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
ONCE Starting when released, Routine
BILIRUBIN, TOTAL
ONCE Starting when released
CREATININE
ONCE Starting when released, Routine
ALBUMIN
ONCE Starting when released
POTASSIUM
ONCE Starting when released, Routine
LD, TOTAL
ONCE Starting when released
URIC ACID
ONCE Starting when released
URINALYSIS WITH MICROSCOPY
NEXT AM Starting S+2 at 0000 until S+3 for 2 occurrences
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or
equal to 50K/µL or Total Bilirubin greater that upper limits of normal.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 9:56:19 AM Page 1 of 15
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Treatment Parameters (2)
Hold treatment and notify authorizing prescriber for Urine Hemoglobin greater than Trace prior to
ifosfamide administration.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient should be treated
in a location to optimize emergency care. See Emergency Medications.
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 10 UNIT/ML lock flush 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 200 mL/hr, Intravenous, CONTINUOUS, For 3 days Starting when released until S+2 at 2359
Day 1 to 3: Begin infusion after the completion of Day 1 etoposide chemotherapy. Adjust maintenance fluid to keep total
fluid at 200 mL/hr and continue hydration throughout chemotherapy and for 6 hours after completion of ifosfamide.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Day 1: Administer first dose prior to start of chemotherapy. If PO not tolerated may give IV.
ondansetron (ZOFRAN) injection 8 mg
8 mg, Intravenous, EVERY 24 HOURS PRN, For 1 day Starting when released until S+1,
nausea/vomiting, for 3 Minutes
Day 1: Administer IV if PO not tolerated. Administer first dose prior to start of chemotherapy. Administer over 3 to 5
minutes.
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous
Day 2: Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting S+1 at 0000
Day 2: Administer prior to chemotherapy. If PO not tolerated may give IV.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, nausea/vomiting
Day 2: Administer prior to chemotherapy. Administer IV if PO not tolerated.
dexamethasone (DECADRON) tab 12 mg
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Zztestonc,PedsBeiber [2668824]
2/4/2016 9:56:19 AM Page 2 of 15
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

12 mg, Oral, ONCE, 1 dose Starting S+1 at 0000
Day 2: Administer first dose prior to start of chemotherapy. If PO not tolerated may give IV.
dexamethasone (DECADRON) 10 MG/ML injection 12 mg
12 mg, Intravenous, EVERY 24 HOURS PRN, For 24 hours Starting S+1 at 0000, nausea/vomiting,
Chemotherapy pre-medication
Day 2: Administer IV if PO not tolerated. Administer prior to chemotherapy.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting S+2 at 0000
Day 3: Administer prior to the start of chemotherapy. If PO not tolerated, may give IV.
ondansetron (ZOFRAN) injection 8 mg
8 mg, Intravenous, EVERY 24 HOURS PRN, For 1 day Starting S+2 at 0000 until S+3, nausea/vomiting,
for 3 Minutes
Day 3: Administer prior to start of chemotherapy. Administer IV if PO not tolerated. Administer over 3 to 5 minutes.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, EVERY 24 HOURS, For 3 days Starting S+2 at 0000
Days 3, 4, and 5: Administer IV if PO not tolerated.
dexamethasone (DECADRON) 10 MG/ML injection 8 mg
8 mg, Intravenous, EVERY 24 HOURS PRN, For 72 hours Starting S+2 at 0000, nausea/vomiting
Days 3, 4, and 5: Administer IV if PO not tolerated.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
dexamethasone (DECADRON) 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
etoposide (VEPESID) 209 mg in sodium chloride 0.9 % 500 mL NSS bag
209 mg (100 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous
Days 1, 2 and 3. Administer with non-PVC tubing over 60 minutes.
ifosfamide (IFEX) 10,450 mg, mesna (MESNEX) 10,450 mg in sodium chloride 0.9 % 1,000 mL bag
10,450 mg (5,000 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous
Day 2: Begin continuous infusion over 24 hours.
CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
(Target AUC = 5), Intravenous
Day 2: Maximum dose = 800 mg. Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See Emergency Medications.
Supportive Care Medications (delete all that do not apply)
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting S+1 at 0000
Day 2: Administer 1 hour after the start of ifosfamide. IV push rate 10 mg/minute.
allopurinol (ZYLOPRIM) tab 300 mg
300 mg, Oral, 1 X DAILY, 10 doses Starting S As Scheduled
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Zztestonc,PedsBeiber [2668824]
2/4/2016 9:56:19 AM Page 3 of 15
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Days 1 through 10: Give daily for 10 days in Cycle 1
acyclovir (ZOVIRAX) tab 400 mg
400 mg, Oral, 2 X DAILY Starting S As Scheduled
fluconazole (DIFLUCAN) tab 400 mg
400 mg, Oral, 1 X DAILY Starting S+1 at 1100
ranitidine (ZANTAC) tab 150 mg
150 mg, Oral, 1 X DAILY Starting when released
sulfamethoxazole-trimethoprim (BACTRIM DS) 800-160 MG per tab 1 tab
1 tab, Oral, 2 X DAILY SAT, SUN Starting when released
Conditional Orders
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
IV push slowly, max rate 5 mg/minute.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
Do not exceed total of 24 mg ondansetron per 24 hours (scheduled and PRN)
ondansetron (ZOFRAN) injection 8 mg
8 mg, Intravenous, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting,
If unable to tolerate PO., for 3 Minutes
Do not exceed total of 24 mg of ondansetron per 24 hours (scheduled and PRN). Administer over 3 to 5 minutes
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
Take 2 tabs by mouth one time daily. Take on Day 4 and 5., 8 mg, Disp-4 tab, R-0, 1 X DAILY starting S,
Local Printer
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed for nausea/vomiting., 8 mg, Disp-30 tab, R-5, EVERY 8
HOURS PRN starting S, Local Printer
Take Home Medications (delete all that do not apply)
TBO-filgrastim (GRANIX) 300 MCG/0.5ML soln prefilled syringe
Inject 300 mcg under skin one time daily in evening. Begin Day ***. Continue until ANC is greater than
*** after nadir., 300 mcg, Disp-10 Syringe, R-5, 1 X DAILY (PM) starting S, Local Printer
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
TBO-filgrastim (GRANIX) 480 MCG/0.8ML soln prefilled syringe
Inject 480 mcg under skin one time daily in evening. Begin Day ***. Continue until ANC is greater than
*** after nadir., 480 mcg, Disp-10 Syringe, R-5, 1 X DAILY (PM) starting S, Local Printer
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
Follow-Up
Verify Appointments
Verify appointment(s) have been scheduled: INTERIM LAB APPOINTMENTS: CBC with DIFF every
Monday and Thursday starting *** and Creatinine, Potassium, Uric Acid, and LDH twice weekly for one week starting ***;
RETURN TO CLINIC for appointment with provider on ***; LABS: CBC with DIFF, Creatinine; ADMIT TO B6/6 on *** for
inpatient chemotherapy treatment.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 9:56:19 AM Page 4 of 15
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Cycle 2 – 2/18/2016 through 3/2/2016 (14 days), Planned
Days 1 through 3 Inpatient , Cycle 2 – Planned for 2/18/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Hodgkin Lymphoma and Hodgkin Lymphoma; THERAPY: etoposide 100 mg/m2/day IV
Day 1 through 3, ifosfamide 5 gm/m2 with mesna 5 gm/m2 IV continuous infusion over 24 hours Day 2, CARBOplatin
(AUC = 5) IV Day 2 (maximum dose = 800mg); CYCLE LENGTH: 14 to 21 days; COURSE: up to 4 cycles. GROWTH
FACTOR REQUIRED.
Note to All Staff (1)
Risk factors associated with ifosfamide neurotoxicity may include hypoalbuminemia, renal dysfunction
(Creatinine Clearance less than 60 mL/min), and prior history of ifosfamide-induced encephalopathy. Consider dose
reduction or methylene blue prophylaxis if present.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
ONCE Starting when released, Routine
BILIRUBIN, TOTAL
ONCE Starting when released
CREATININE
ONCE Starting when released, Routine
ALBUMIN
ONCE Starting when released
URINALYSIS WITH MICROSCOPY
NEXT AM Starting S+2 at 0000 until S+3 for 2 occurrences
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or
equal to 50K/µL or Total Bilirubin greater that upper limits of normal.
Treatment Parameters (2)
Hold treatment and notify authorizing prescriber for Urine Hemoglobin greater than Trace prior to
ifosfamide administration.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient should be treated
in a location to optimize emergency care. See Emergency Medications.
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,PedsBeiber [2668824]
2/4/2016 9:56:19 AM Page 5 of 15
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@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 10 UNIT/ML lock flush 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 200 mL/hr, Intravenous, CONTINUOUS, For 3 days Starting when released until S+2 at 2359
Day 1 to 3: Begin infusion after the completion of Day 1 etoposide chemotherapy. Adjust maintenance fluid to keep total
fluid at 200 mL/hr and continue hydration throughout chemotherapy and for 6 hours after completion of ifosfamide.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Day 1: Administer first dose prior to start of chemotherapy. If PO not tolerated may give IV.
ondansetron (ZOFRAN) injection 8 mg
8 mg, Intravenous, EVERY 24 HOURS PRN, For 1 day Starting when released until S+1,
nausea/vomiting, for 3 Minutes
Day 1: Administer IV if PO not tolerated. Administer first dose prior to start of chemotherapy. Administer over 3 to 5
minutes.
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous
Day 2: Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting S+1 at 0000
Day 2: Administer prior to chemotherapy. If PO not tolerated may give IV.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, nausea/vomiting
Day 2: Administer prior to chemotherapy. Administer IV if PO not tolerated.
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting S+1 at 0000
Day 2: Administer first dose prior to start of chemotherapy. If PO not tolerated may give IV.
dexamethasone (DECADRON) 10 MG/ML injection 12 mg
12 mg, Intravenous, EVERY 24 HOURS PRN, For 24 hours Starting S+1 at 0000, nausea/vomiting,
Chemotherapy pre-medication
Day 2: Administer IV if PO not tolerated. Administer prior to chemotherapy.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting S+2 at 0000
Day 3: Administer prior to the start of chemotherapy. If PO not tolerated, may give IV.
ondansetron (ZOFRAN) injection 8 mg
8 mg, Intravenous, EVERY 24 HOURS PRN, For 1 day Starting S+2 at 0000 until S+3, nausea/vomiting,
for 3 Minutes
Day 3: Administer prior to start of chemotherapy. Administer IV if PO not tolerated. Administer over 3 to 5 minutes.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 9:56:19 AM Page 6 of 15
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, EVERY 24 HOURS, For 3 days Starting S+2 at 0000
Days 3, 4, and 5: Administer IV if PO not tolerated.
dexamethasone (DECADRON) 10 MG/ML injection 8 mg
8 mg, Intravenous, EVERY 24 HOURS PRN, For 72 hours Starting S+2 at 0000, nausea/vomiting
Days 3, 4, and 5: Administer IV if PO not tolerated.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
dexamethasone (DECADRON) 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
etoposide (VEPESID) 209 mg in sodium chloride 0.9 % 500 mL NSS bag
209 mg (100 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous
Days 1, 2 and 3. Administer with non-PVC tubing over 60 minutes.
ifosfamide (IFEX) 10,450 mg, mesna (MESNEX) 10,450 mg in sodium chloride 0.9 % 1,000 mL bag
10,450 mg (5,000 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous
Day 2: Begin continuous infusion over 24 hours.
CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
(Target AUC = 5), Intravenous
Day 2: Maximum dose = 800 mg. Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See Emergency Medications.
Supportive Care Medications (delete all that do not apply)
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting S+1 at 0000
Day 2: Administer 1 hour after the start of ifosfamide. IV push rate 10 mg/minute.
acyclovir (ZOVIRAX) tab 400 mg
400 mg, Oral, 2 X DAILY Starting S As Scheduled
fluconazole (DIFLUCAN) tab 400 mg
400 mg, Oral, 1 X DAILY Starting S+1 at 1100
ranitidine (ZANTAC) tab 150 mg
150 mg, Oral, 1 X DAILY Starting when released
sulfamethoxazole-trimethoprim (BACTRIM DS) 800-160 MG per tab 1 tab
1 tab, Oral, 2 X DAILY SAT, SUN Starting when released
Conditional Orders
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
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Zztestonc,PedsBeiber [2668824]
2/4/2016 9:56:19 AM Page 7 of 15
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
IV push slowly, max rate 5 mg/minute.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
Do not exceed total of 24 mg ondansetron per 24 hours (scheduled and PRN)
ondansetron (ZOFRAN) injection 8 mg
8 mg, Intravenous, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting,
If unable to tolerate PO., for 3 Minutes
Do not exceed total of 24 mg of ondansetron per 24 hours (scheduled and PRN). Administer over 3 to 5 minutes
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
Take 2 tabs by mouth one time daily. Take on Day 4 and 5., 8 mg, Disp-4 tab, R-0, 1 X DAILY starting S,
Local Printer
Follow-Up
Verify Appointments
Verify appointment(s) have been scheduled: INTERIM LAB APPOINTMENTS: CBC with DIFF every
Monday and Thursday starting ***; RETURN TO CLINIC for appointment with provider on ***; LABS: CBC with DIFF,
Creatinine; ADMIT TO B6/6 on *** for inpatient chemotherapy treatment.
Cycle 3 – 3/3/2016 through 3/16/2016 (14 days), Planned
Days 1 through 3 Inpatient , Cycle 3 – Planned for 3/3/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Hodgkin Lymphoma and Hodgkin Lymphoma; THERAPY: etoposide 100 mg/m2/day IV
Day 1 through 3, ifosfamide 5 gm/m2 with mesna 5 gm/m2 IV continuous infusion over 24 hours Day 2, CARBOplatin
(AUC = 5) IV Day 2 (maximum dose = 800mg); CYCLE LENGTH: 14 to 21 days; COURSE: up to 4 cycles. GROWTH
FACTOR REQUIRED.
Note to All Staff (1)
Risk factors associated with ifosfamide neurotoxicity may include hypoalbuminemia, renal dysfunction
(Creatinine Clearance less than 60 mL/min), and prior history of ifosfamide-induced encephalopathy. Consider dose
reduction or methylene blue prophylaxis if present.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
ONCE Starting when released, Routine
BILIRUBIN, TOTAL
ONCE Starting when released
CREATININE
ONCE Starting when released, Routine
ALBUMIN
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Zztestonc,PedsBeiber [2668824]
2/4/2016 9:56:19 AM Page 8 of 15
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

ONCE Starting when released
URINALYSIS WITH MICROSCOPY
NEXT AM Starting S+2 at 0000 until S+3 for 2 occurrences
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or
equal to 50K/µL or Total Bilirubin greater that upper limits of normal.
Treatment Parameters (2)
Hold treatment and notify authorizing prescriber for Urine Hemoglobin greater than Trace prior to
ifosfamide administration.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient should be treated
in a location to optimize emergency care. See Emergency Medications.
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 10 UNIT/ML lock flush 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 200 mL/hr, Intravenous, CONTINUOUS, For 3 days Starting when released until S+2 at 2359
Day 1 to 3: Begin infusion after the completion of Day 1 etoposide chemotherapy. Adjust maintenance fluid to keep total
fluid at 200 mL/hr and continue hydration throughout chemotherapy and for 6 hours after completion of ifosfamide.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Day 1: Administer first dose prior to start of chemotherapy. If PO not tolerated may give IV.
ondansetron (ZOFRAN) injection 8 mg
8 mg, Intravenous, EVERY 24 HOURS PRN, For 1 day Starting when released until S+1,
nausea/vomiting, for 3 Minutes
Day 1: Administer IV if PO not tolerated. Administer first dose prior to start of chemotherapy. Administer over 3 to 5
minutes.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 9:56:19 AM Page 9 of 15
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous
Day 2: Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting S+1 at 0000
Day 2: Administer prior to chemotherapy. If PO not tolerated may give IV.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, nausea/vomiting
Day 2: Administer prior to chemotherapy. Administer IV if PO not tolerated.
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting S+1 at 0000
Day 2: Administer first dose prior to start of chemotherapy. If PO not tolerated may give IV.
dexamethasone (DECADRON) 10 MG/ML injection 12 mg
12 mg, Intravenous, EVERY 24 HOURS PRN, For 24 hours Starting S+1 at 0000, nausea/vomiting,
Chemotherapy pre-medication
Day 2: Administer IV if PO not tolerated. Administer prior to chemotherapy.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting S+2 at 0000
Day 3: Administer prior to the start of chemotherapy. If PO not tolerated, may give IV.
ondansetron (ZOFRAN) injection 8 mg
8 mg, Intravenous, EVERY 24 HOURS PRN, For 1 day Starting S+2 at 0000 until S+3, nausea/vomiting,
for 3 Minutes
Day 3: Administer prior to start of chemotherapy. Administer IV if PO not tolerated. Administer over 3 to 5 minutes.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, EVERY 24 HOURS, For 3 days Starting S+2 at 0000
Days 3, 4, and 5: Administer IV if PO not tolerated.
dexamethasone (DECADRON) 10 MG/ML injection 8 mg
8 mg, Intravenous, EVERY 24 HOURS PRN, For 72 hours Starting S+2 at 0000, nausea/vomiting
Days 3, 4, and 5: Administer IV if PO not tolerated.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
dexamethasone (DECADRON) 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
etoposide (VEPESID) 209 mg in sodium chloride 0.9 % 500 mL NSS bag
209 mg (100 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous
Days 1, 2 and 3. Administer with non-PVC tubing over 60 minutes.
ifosfamide (IFEX) 10,450 mg, mesna (MESNEX) 10,450 mg in sodium chloride 0.9 % 1,000 mL bag
10,450 mg (5,000 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous
Day 2: Begin continuous infusion over 24 hours.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 9:56:19 AM Page 10 of 15
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
(Target AUC = 5), Intravenous
Day 2: Maximum dose = 800 mg. Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See Emergency Medications.
Supportive Care Medications (delete all that do not apply)
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting S+1 at 0000
Day 2: Administer 1 hour after the start of ifosfamide. IV push rate 10 mg/minute.
acyclovir (ZOVIRAX) tab 400 mg
400 mg, Oral, 2 X DAILY Starting S As Scheduled
fluconazole (DIFLUCAN) tab 400 mg
400 mg, Oral, 1 X DAILY Starting S+1 at 1100
ranitidine (ZANTAC) tab 150 mg
150 mg, Oral, 1 X DAILY Starting when released
sulfamethoxazole-trimethoprim (BACTRIM DS) 800-160 MG per tab 1 tab
1 tab, Oral, 2 X DAILY SAT, SUN Starting when released
Conditional Orders
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
IV push slowly, max rate 5 mg/minute.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
Do not exceed total of 24 mg ondansetron per 24 hours (scheduled and PRN)
ondansetron (ZOFRAN) injection 8 mg
8 mg, Intravenous, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting,
If unable to tolerate PO., for 3 Minutes
Do not exceed total of 24 mg of ondansetron per 24 hours (scheduled and PRN). Administer over 3 to 5 minutes
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
Take 2 tabs by mouth one time daily. Take on Day 4 and 5., 8 mg, Disp-4 tab, R-0, 1 X DAILY starting S,
Local Printer
Follow-Up
Verify Appointments
Verify appointment(s) have been scheduled: INTERIM LAB APPOINTMENTS: CBC with DIFF every
Monday and Thursday starting ***; RETURN TO CLINIC for appointment with provider on ***; LABS: CBC with DIFF,
Creatinine; ADMIT TO B6/6 on *** for inpatient chemotherapy treatment.
Cycle 4 – 3/17/2016 through 3/30/2016 (14 days), Planned
Days 1 through 3 Inpatient , Cycle 4 – Planned for 3/17/2016
Treatment Plan Information
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Zztestonc,PedsBeiber [2668824]
2/4/2016 9:56:19 AM Page 11 of 15
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Non-Hodgkin Lymphoma and Hodgkin Lymphoma; THERAPY: etoposide 100 mg/m2/day IV
Day 1 through 3, ifosfamide 5 gm/m2 with mesna 5 gm/m2 IV continuous infusion over 24 hours Day 2, CARBOplatin
(AUC = 5) IV Day 2 (maximum dose = 800mg); CYCLE LENGTH: 14 to 21 days; COURSE: up to 4 cycles. GROWTH
FACTOR REQUIRED.
Note to All Staff (1)
Risk factors associated with ifosfamide neurotoxicity may include hypoalbuminemia, renal dysfunction
(Creatinine Clearance less than 60 mL/min), and prior history of ifosfamide-induced encephalopathy. Consider dose
reduction or methylene blue prophylaxis if present.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
ONCE Starting when released, Routine
BILIRUBIN, TOTAL
ONCE Starting when released
CREATININE
ONCE Starting when released, Routine
ALBUMIN
ONCE Starting when released
URINALYSIS WITH MICROSCOPY
NEXT AM Starting S+2 at 0000 until S+3 for 2 occurrences
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or
equal to 50K/µL or Total Bilirubin greater that upper limits of normal.
Treatment Parameters (2)
Hold treatment and notify authorizing prescriber for Urine Hemoglobin greater than Trace prior to
ifosfamide administration.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient should be treated
in a location to optimize emergency care. See Emergency Medications.
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
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Zztestonc,PedsBeiber [2668824]
2/4/2016 9:56:19 AM Page 12 of 15
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush 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 200 mL/hr, Intravenous, CONTINUOUS, For 3 days Starting when released until S+2 at 2359
Day 1 to 3: Begin infusion after the completion of Day 1 etoposide chemotherapy. Adjust maintenance fluid to keep total
fluid at 200 mL/hr and continue hydration throughout chemotherapy and for 6 hours after completion of ifosfamide.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Day 1: Administer first dose prior to start of chemotherapy. If PO not tolerated may give IV.
ondansetron (ZOFRAN) injection 8 mg
8 mg, Intravenous, EVERY 24 HOURS PRN, For 1 day Starting when released until S+1,
nausea/vomiting, for 3 Minutes
Day 1: Administer IV if PO not tolerated. Administer first dose prior to start of chemotherapy. Administer over 3 to 5
minutes.
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous
Day 2: Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting S+1 at 0000
Day 2: Administer prior to chemotherapy. If PO not tolerated may give IV.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, nausea/vomiting
Day 2: Administer prior to chemotherapy. Administer IV if PO not tolerated.
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting S+1 at 0000
Day 2: Administer first dose prior to start of chemotherapy. If PO not tolerated may give IV.
dexamethasone (DECADRON) 10 MG/ML injection 12 mg
12 mg, Intravenous, EVERY 24 HOURS PRN, For 24 hours Starting S+1 at 0000, nausea/vomiting,
Chemotherapy pre-medication
Day 2: Administer IV if PO not tolerated. Administer prior to chemotherapy.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting S+2 at 0000
Day 3: Administer prior to the start of chemotherapy. If PO not tolerated, may give IV.
ondansetron (ZOFRAN) injection 8 mg
8 mg, Intravenous, EVERY 24 HOURS PRN, For 1 day Starting S+2 at 0000 until S+3, nausea/vomiting,
for 3 Minutes
Day 3: Administer prior to start of chemotherapy. Administer IV if PO not tolerated. Administer over 3 to 5 minutes.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, EVERY 24 HOURS, For 3 days Starting S+2 at 0000
Days 3, 4, and 5: Administer IV if PO not tolerated.
dexamethasone (DECADRON) 10 MG/ML injection 8 mg
8 mg, Intravenous, EVERY 24 HOURS PRN, For 72 hours Starting S+2 at 0000, nausea/vomiting
Days 3, 4, and 5: Administer IV if PO not tolerated.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 9:56:19 AM Page 13 of 15
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
dexamethasone (DECADRON) 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
etoposide (VEPESID) 209 mg in sodium chloride 0.9 % 500 mL NSS bag
209 mg (100 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous
Days 1, 2 and 3. Administer with non-PVC tubing over 60 minutes.
ifosfamide (IFEX) 10,450 mg, mesna (MESNEX) 10,450 mg in sodium chloride 0.9 % 1,000 mL bag
10,450 mg (5,000 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous
Day 2: Begin continuous infusion over 24 hours.
CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
(Target AUC = 5), Intravenous
Day 2: Maximum dose = 800 mg. Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See Emergency Medications.
Supportive Care Medications (delete all that do not apply)
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting S+1 at 0000
Day 2: Administer 1 hour after the start of ifosfamide. IV push rate 10 mg/minute.
acyclovir (ZOVIRAX) tab 400 mg
400 mg, Oral, 2 X DAILY Starting S As Scheduled
fluconazole (DIFLUCAN) tab 400 mg
400 mg, Oral, 1 X DAILY Starting S+1 at 1100
ranitidine (ZANTAC) tab 150 mg
150 mg, Oral, 1 X DAILY Starting when released
sulfamethoxazole-trimethoprim (BACTRIM DS) 800-160 MG per tab 1 tab
1 tab, Oral, 2 X DAILY SAT, SUN Starting when released
Conditional Orders
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
IV push slowly, max rate 5 mg/minute.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
Do not exceed total of 24 mg ondansetron per 24 hours (scheduled and PRN)
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Zztestonc,PedsBeiber [2668824]
2/4/2016 9:56:19 AM Page 14 of 15
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

ondansetron (ZOFRAN) injection 8 mg
8 mg, Intravenous, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting,
If unable to tolerate PO., for 3 Minutes
Do not exceed total of 24 mg of ondansetron per 24 hours (scheduled and PRN). Administer over 3 to 5 minutes
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
Take 2 tabs by mouth one time daily. Take on Day 4 and 5., 8 mg, Disp-4 tab, R-0, 1 X DAILY starting S,
Local Printer
Follow-Up
Verify Appointments
Verify appointment(s) have been scheduled: INTERIM LAB APPOINTMENTS: CBC with DIFF every
Monday and Thursday starting ***; RETURN TO CLINIC for appointment with provider on ***; LABS: CBC with DIFF,
Creatinine; ADMIT TO B6/6 on *** for inpatient chemotherapy treatment.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 9:56:19 AM Page 15 of 15
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org