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

CSC Sarcoma (VAC) Cyclophosphamide Dactinomycin Vincristine VER 5-1-17 (HL 4188)

CSC Sarcoma (VAC) Cyclophosphamide Dactinomycin Vincristine VER 5-1-17 (HL 4188) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Sarcoma


CSC SARCOMA (VAC) CYCLOPHOSPHAMIDE DACTINOMYCIN VINCRISTINE VER 5-1-17 (HL 4188) – Properties
Pre-Cycle – 6/6/2017 through 6/12/2017 (7 days), Planned
Day 1, Pre-Cycle – Planned for 6/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Adjuvant); THERAPY: mesna 800 mg IV/PO prior to, 4 and 8 hours after each cyclophosphamide
dose; Cycle 1 through 4: vinCRISTine 1.5 mg/m2 IV (maximum dose for each treatment day = 2 mg) Day 1,8, and 15;
DACTINOmycin 45 mcg/kg IV (maximum dose for each treatment day = 2.5 mg) Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle
5: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 6:
vinCRISTine 1.5 mg/m2 IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 7: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 8: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 9 through 11: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 12: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 13 and 14: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; LENGTH: 21 days; COURSE: 14 cycles
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S Approximate, Expires-S+365, Routine
BUN
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S Approximate, Expires-S+365, Routine
Take Home Medications
aprepitant (EMEND) 80 MG cap
Take 1 cap by mouth one time daily. Take for 2 days following treatment., 80 mg, Disp-2 cap, R-13, 1 X DAILY starting S
dexamethasone (DECADRON) 4 MG tab
Take 2 tabs by mouth one time daily. Take for 3 days following chemotherapy, 8 mg, Disp-42 tab, R-1, 1 X DAILY 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
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Zztestonc,Jeff J [2507481]
6/13/2017 8:27:25 AM Page 1 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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.
Cycle 1 – 6/13/2017 through 7/3/2017 (21 days), Planned
Day 1, Cycle 1 – Planned for 6/13/2017
Treatment Plan Information
Reference Information (1)
SARCOMA: Arndt CA, et al. J Clin Oncol 2009;27(31):5182-8.
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Adjuvant); THERAPY: mesna 800 mg IV/PO prior to, 4 and 8 hours after each cyclophosphamide
dose; Cycle 1 through 4: vinCRISTine 1.5 mg/m2 IV (maximum dose for each treatment day = 2 mg) Day 1,8, and 15;
DACTINOmycin 45 mcg/kg IV (maximum dose for each treatment day = 2.5 mg) Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle
5: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 6:
vinCRISTine 1.5 mg/m2 IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 7: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 8: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 9 through 11: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 12: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 13 and 14: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; LENGTH: 21 days; COURSE: 14 cycles
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Platelets, Creatinine, Total Bilirubin
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than ULN or Total Bilirubin greater than ULN.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of, and for two days after cyclophosphamide
treatment.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
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Zztestonc,Jeff J [2507481]
6/13/2017 8:27:25 AM Page 2 of 49
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
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to cyclophosphamide.
Treatment Medications
vinCRIStine (ONCOVIN) 2.9 mg in sodium chloride 0.9 % 25 mL bag
2.9 mg (rounded from 2.94 mg = 1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3-5 Minutes
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
DACTINOmycin (COSMOGEN) injection 3,600 mcg
3,600 mcg (45 mcg/kg × 80 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
IV push over 1-5 minutes into running IV. Max dose = 2500 mcg.
mesna (MESNEX) 800 mg in dextrose 5 % 50 mL bag
800 mg, Intravenous, ONCE, 1 dose Starting when released
Give prior to start of cyclophosphamide.
cyclophosphamide (CYTOXAN) 4,312 mg bag
4,312 mg (2,200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Treatment Medications (delete all that do not apply)
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): mesna oral at 4 hours and 8 hours after the
start of cyclophosphamide. (See Day 1 of Cycle 1)
mesna (MESNEX) 800 mg in dextrose 5 % 50 mL bag
800 mg, Intravenous, EVERY 4 HOURS, 2 doses Starting when released
Doses to be given 4 and 8 hours after cyclophosphamide. Omit if given PO
Take Home Medications
mesna (MESNEX) 400 MG tab
Take 2 tabs by mouth 2 times daily. Take 4 & 8 hours after start of cyclophosphamide., 800 mg, Disp-4 tab, R-13, 2 X DAILY
starting S
MD may delete this order and order IV mesna.
Follow-Up
DAY 8 FOLLOW-UP
RETURN TO CLINIC; LABS: CBC (DIFF if done locally), ANC; CHEMOTHERAPY ROOM APPOINTMENT: vinCRISTine for 30
minutes.
DAY 15 FOLLOW-UP
RETURN TO CLINIC; LABS: CBC (DIFF if done locally), ANC; CHEMOTHERAPY ROOM APPOINTMENT: vinCRISTine for 30
minutes.
DAY 22 FOLLOW-UP
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
Ordered dose of 45 mcg/kg ONCE exceeds the recommended single dose limit of 2,500 mcg.
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Zztestonc,Jeff J [2507481]
6/13/2017 8:27:25 AM Page 3 of 49
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 (DIFF if done locally), ANC, Sodium,
Potassium, Chloride, Carbon Dioxide, BUN, Creatinine, Glucose, Total Bilirubin, AST, ALT, Alkaline Phosphatase;
CHEMOTHERAPY ROOM APPOINTMENT: vinCRIStine, DACTINOmycin, mesna, cyclophosphamide for 150 minutes.
Day 8, Cycle 1 – Planned for 6/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Adjuvant); THERAPY: mesna 800 mg IV/PO prior to, 4 and 8 hours after each cyclophosphamide
dose; Cycle 1 through 4: vinCRISTine 1.5 mg/m2 IV (maximum dose for each treatment day = 2 mg) Day 1,8, and 15;
DACTINOmycin 45 mcg/kg IV (maximum dose for each treatment day = 2.5 mg) Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle
5: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 6:
vinCRISTine 1.5 mg/m2 IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 7: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 8: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 9 through 11: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 12: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 13 and 14: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; LENGTH: 21 days; COURSE: 14 cycles
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
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 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
vinCRIStine (ONCOVIN) 2.9 mg in sodium chloride 0.9 % 25 mL bag
2.9 mg (rounded from 2.94 mg = 1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3-5 Minutes
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
Follow-Up
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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Zztestonc,Jeff J [2507481]
6/13/2017 8:27:25 AM Page 4 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Verify Appointments
Verify next day appointment(s) have been scheduled.
Day 15, Cycle 1 – Planned for 6/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Adjuvant); THERAPY: mesna 800 mg IV/PO prior to, 4 and 8 hours after each cyclophosphamide
dose; Cycle 1 through 4: vinCRISTine 1.5 mg/m2 IV (maximum dose for each treatment day = 2 mg) Day 1,8, and 15;
DACTINOmycin 45 mcg/kg IV (maximum dose for each treatment day = 2.5 mg) Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle
5: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 6:
vinCRISTine 1.5 mg/m2 IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 7: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 8: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 9 through 11: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 12: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 13 and 14: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; LENGTH: 21 days; COURSE: 14 cycles
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
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 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
vinCRIStine (ONCOVIN) 2.9 mg in sodium chloride 0.9 % 25 mL bag
2.9 mg (rounded from 2.94 mg = 1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3-5 Minutes
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
Follow-Up
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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Zztestonc,Jeff J [2507481]
6/13/2017 8:27:25 AM Page 5 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Verify Appointments
Verify next day appointment(s) have been scheduled.
Cycle 2 – 7/4/2017 through 7/24/2017 (21 days), Planned
Day 1, Cycle 2 – Planned for 7/4/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Adjuvant); THERAPY: mesna 800 mg IV/PO prior to, 4 and 8 hours after each cyclophosphamide
dose; Cycle 1 through 4: vinCRISTine 1.5 mg/m2 IV (maximum dose for each treatment day = 2 mg) Day 1,8, and 15;
DACTINOmycin 45 mcg/kg IV (maximum dose for each treatment day = 2.5 mg) Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle
5: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 6:
vinCRISTine 1.5 mg/m2 IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 7: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 8: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 9 through 11: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 12: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 13 and 14: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; LENGTH: 21 days; COURSE: 14 cycles
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+7 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Platelets, Creatinine, Total Bilirubin
Treatment Parameters
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Zztestonc,Jeff J [2507481]
6/13/2017 8:27:25 AM Page 6 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than ULN or Total Bilirubin greater than ULN.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of, and for two days after cyclophosphamide
treatment.
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
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to cyclophosphamide.
Treatment Medications
vinCRIStine (ONCOVIN) 2.9 mg in sodium chloride 0.9 % 25 mL bag
2.9 mg (rounded from 2.94 mg = 1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3-5 Minutes
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
DACTINOmycin (COSMOGEN) injection 3,600 mcg
3,600 mcg (45 mcg/kg × 80 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
IV push over 1-5 minutes into running IV. Max dose = 2500 mcg.
mesna (MESNEX) 800 mg in dextrose 5 % 50 mL bag
800 mg, Intravenous, ONCE, 1 dose Starting when released
Give prior to start of cyclophosphamide.
cyclophosphamide (CYTOXAN) 4,312 mg bag
4,312 mg (2,200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Treatment Medications (delete all that do not apply)
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): mesna oral at 4 hours and 8 hours after the
start of cyclophosphamide. (See Day 1 of Cycle 1)
mesna (MESNEX) 800 mg in dextrose 5 % 50 mL bag
800 mg, Intravenous, EVERY 4 HOURS, 2 doses Starting when released
Doses to be given 4 and 8 hours after cyclophosphamide. Omit if given PO
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
Ordered dose of 45 mcg/kg ONCE exceeds the recommended single dose limit of 2,500 mcg.
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Zztestonc,Jeff J [2507481]
6/13/2017 8:27:25 AM Page 7 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Follow-Up
DAY 8 FOLLOW-UP
RETURN TO CLINIC; LABS: CBC (DIFF if done locally), ANC; CHEMOTHERAPY ROOM APPOINTMENT: vinCRISTine for 30
minutes.
DAY 15 FOLLOW-UP
RETURN TO CLINIC; LABS: CBC (DIFF if done locally), ANC; CHEMOTHERAPY ROOM APPOINTMENT: vinCRISTine for 30
minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC (DIFF if done locally), ANC, Sodium,
Potassium, Chloride, Carbon Dioxide, BUN, Creatinine, Glucose, Total Bilirubin, AST, ALT, Alkaline Phosphatase;
CHEMOTHERAPY ROOM APPOINTMENT: vinCRIStine, DACTINOmycin, mesna, cyclophosphamide for 150 minutes.
Day 8, Cycle 2 – Planned for 7/11/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Adjuvant); THERAPY: mesna 800 mg IV/PO prior to, 4 and 8 hours after each cyclophosphamide
dose; Cycle 1 through 4: vinCRISTine 1.5 mg/m2 IV (maximum dose for each treatment day = 2 mg) Day 1,8, and 15;
DACTINOmycin 45 mcg/kg IV (maximum dose for each treatment day = 2.5 mg) Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle
5: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 6:
vinCRISTine 1.5 mg/m2 IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 7: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 8: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 9 through 11: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 12: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 13 and 14: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; LENGTH: 21 days; COURSE: 14 cycles
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
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 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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Zztestonc,Jeff J [2507481]
6/13/2017 8:27:25 AM Page 8 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Medications
vinCRIStine (ONCOVIN) 2.9 mg in sodium chloride 0.9 % 25 mL bag
2.9 mg (rounded from 2.94 mg = 1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3-5 Minutes
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
Follow-Up
Verify Appointments
Verify next day appointment(s) have been scheduled.
Day 15, Cycle 2 – Planned for 7/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Adjuvant); THERAPY: mesna 800 mg IV/PO prior to, 4 and 8 hours after each cyclophosphamide
dose; Cycle 1 through 4: vinCRISTine 1.5 mg/m2 IV (maximum dose for each treatment day = 2 mg) Day 1,8, and 15;
DACTINOmycin 45 mcg/kg IV (maximum dose for each treatment day = 2.5 mg) Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle
5: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 6:
vinCRISTine 1.5 mg/m2 IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 7: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 8: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 9 through 11: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 12: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 13 and 14: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; LENGTH: 21 days; COURSE: 14 cycles
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
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 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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Zztestonc,Jeff J [2507481]
6/13/2017 8:27:25 AM Page 9 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Medications
vinCRIStine (ONCOVIN) 2.9 mg in sodium chloride 0.9 % 25 mL bag
2.9 mg (rounded from 2.94 mg = 1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3-5 Minutes
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
Follow-Up
Verify Appointments
Verify next day appointment(s) have been scheduled.
Cycle 3 – 7/25/2017 through 8/14/2017 (21 days), Planned
Day 1, Cycle 3 – Planned for 7/25/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Adjuvant); THERAPY: mesna 800 mg IV/PO prior to, 4 and 8 hours after each cyclophosphamide
dose; Cycle 1 through 4: vinCRISTine 1.5 mg/m2 IV (maximum dose for each treatment day = 2 mg) Day 1,8, and 15;
DACTINOmycin 45 mcg/kg IV (maximum dose for each treatment day = 2.5 mg) Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle
5: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 6:
vinCRISTine 1.5 mg/m2 IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 7: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 8: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 9 through 11: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 12: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 13 and 14: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; LENGTH: 21 days; COURSE: 14 cycles
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Routine
ALT/SGPT
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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Zztestonc,Jeff J [2507481]
6/13/2017 8:27:25 AM Page 10 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Expected-S+7 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Platelets, Creatinine, Total Bilirubin
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than ULN or Total Bilirubin greater than ULN.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of, and for two days after cyclophosphamide
treatment.
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
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to cyclophosphamide.
Treatment Medications
vinCRIStine (ONCOVIN) 2.9 mg in sodium chloride 0.9 % 25 mL bag
2.9 mg (rounded from 2.94 mg = 1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3-5 Minutes
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
DACTINOmycin (COSMOGEN) injection 3,600 mcg
3,600 mcg (45 mcg/kg × 80 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
IV push over 1-5 minutes into running IV. Max dose = 2500 mcg.
mesna (MESNEX) 800 mg in dextrose 5 % 50 mL bag
800 mg, Intravenous, ONCE, 1 dose Starting when released
Give prior to start of cyclophosphamide.
cyclophosphamide (CYTOXAN) 4,312 mg bag
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
Ordered dose of 45 mcg/kg ONCE exceeds the recommended single dose limit of 2,500 mcg.
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Zztestonc,Jeff J [2507481]
6/13/2017 8:27:25 AM Page 11 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

4,312 mg (2,200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Treatment Medications (delete all that do not apply)
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): mesna oral at 4 hours and 8 hours after the
start of cyclophosphamide. (See Day 1 of Cycle 1)
mesna (MESNEX) 800 mg in dextrose 5 % 50 mL bag
800 mg, Intravenous, EVERY 4 HOURS, 2 doses Starting when released
Doses to be given 4 and 8 hours after cyclophosphamide. Omit if given PO
Follow-Up
DAY 8 FOLLOW-UP
RETURN TO CLINIC; LABS: CBC (DIFF if done locally), ANC; CHEMOTHERAPY ROOM APPOINTMENT: vinCRISTine for 30
minutes.
DAY 15 FOLLOW-UP
RETURN TO CLINIC; LABS: CBC (DIFF if done locally), ANC; CHEMOTHERAPY ROOM APPOINTMENT: vinCRISTine for 30
minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC (DIFF if done locally), ANC, Sodium,
Potassium, Chloride, Carbon Dioxide, BUN, Creatinine, Glucose, Total Bilirubin, AST, ALT, Alkaline Phosphatase;
CHEMOTHERAPY ROOM APPOINTMENT: vinCRIStine, DACTINOmycin, mesna, cyclophosphamide for 150 minutes.
Day 8, Cycle 3 – Planned for 8/1/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Adjuvant); THERAPY: mesna 800 mg IV/PO prior to, 4 and 8 hours after each cyclophosphamide
dose; Cycle 1 through 4: vinCRISTine 1.5 mg/m2 IV (maximum dose for each treatment day = 2 mg) Day 1,8, and 15;
DACTINOmycin 45 mcg/kg IV (maximum dose for each treatment day = 2.5 mg) Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle
5: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 6:
vinCRISTine 1.5 mg/m2 IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 7: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 8: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 9 through 11: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 12: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 13 and 14: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; LENGTH: 21 days; COURSE: 14 cycles
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
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
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Zztestonc,Jeff J [2507481]
6/13/2017 8:27:25 AM Page 12 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
vinCRIStine (ONCOVIN) 2.9 mg in sodium chloride 0.9 % 25 mL bag
2.9 mg (rounded from 2.94 mg = 1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3-5 Minutes
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
Follow-Up
Verify Appointments
Verify next day appointment(s) have been scheduled.
Day 15, Cycle 3 – Planned for 8/8/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Adjuvant); THERAPY: mesna 800 mg IV/PO prior to, 4 and 8 hours after each cyclophosphamide
dose; Cycle 1 through 4: vinCRISTine 1.5 mg/m2 IV (maximum dose for each treatment day = 2 mg) Day 1,8, and 15;
DACTINOmycin 45 mcg/kg IV (maximum dose for each treatment day = 2.5 mg) Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle
5: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 6:
vinCRISTine 1.5 mg/m2 IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 7: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 8: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 9 through 11: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 12: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 13 and 14: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; LENGTH: 21 days; COURSE: 14 cycles
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
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
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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Zztestonc,Jeff J [2507481]
6/13/2017 8:27:25 AM Page 13 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
vinCRIStine (ONCOVIN) 2.9 mg in sodium chloride 0.9 % 25 mL bag
2.9 mg (rounded from 2.94 mg = 1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3-5 Minutes
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
Follow-Up
Verify Appointments
Verify next day appointment(s) have been scheduled.
Cycle 4 – 8/15/2017 through 9/4/2017 (21 days), Planned
Day 1, Cycle 4 – Planned for 8/15/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Adjuvant); THERAPY: mesna 800 mg IV/PO prior to, 4 and 8 hours after each cyclophosphamide
dose; Cycle 1 through 4: vinCRISTine 1.5 mg/m2 IV (maximum dose for each treatment day = 2 mg) Day 1,8, and 15;
DACTINOmycin 45 mcg/kg IV (maximum dose for each treatment day = 2.5 mg) Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle
5: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 6:
vinCRISTine 1.5 mg/m2 IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 7: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 8: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 9 through 11: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 12: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 13 and 14: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; LENGTH: 21 days; COURSE: 14 cycles
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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Zztestonc,Jeff J [2507481]
6/13/2017 8:27:25 AM Page 14 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+7 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Platelets, Creatinine, Total Bilirubin
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than ULN or Total Bilirubin greater than ULN.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of, and for two days after cyclophosphamide
treatment.
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
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to cyclophosphamide.
Treatment Medications
vinCRIStine (ONCOVIN) 2.9 mg in sodium chloride 0.9 % 25 mL bag
2.9 mg (rounded from 2.94 mg = 1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3-5 Minutes
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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Zztestonc,Jeff J [2507481]
6/13/2017 8:27:25 AM Page 15 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

DACTINOmycin (COSMOGEN) injection 3,600 mcg
3,600 mcg (45 mcg/kg × 80 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
IV push over 1-5 minutes into running IV. Max dose = 2500 mcg.
mesna (MESNEX) 800 mg in dextrose 5 % 50 mL bag
800 mg, Intravenous, ONCE, 1 dose Starting when released
Give prior to start of cyclophosphamide.
cyclophosphamide (CYTOXAN) 4,312 mg bag
4,312 mg (2,200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Treatment Medications (delete all that do not apply)
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): mesna oral at 4 hours and 8 hours after the
start of cyclophosphamide. (See Day 1 of Cycle 1)
mesna (MESNEX) 800 mg in dextrose 5 % 50 mL bag
800 mg, Intravenous, EVERY 4 HOURS, 2 doses Starting when released
Doses to be given 4 and 8 hours after cyclophosphamide. Omit if given PO
Follow-Up
DAY 8 FOLLOW-UP
RETURN TO CLINIC; LABS: CBC (DIFF if done locally), ANC; CHEMOTHERAPY ROOM APPOINTMENT: vinCRISTine for 30
minutes.
DAY 15 FOLLOW-UP
RETURN TO CLINIC; LABS: CBC (DIFF if done locally), ANC; CHEMOTHERAPY ROOM APPOINTMENT: vinCRISTine for 30
minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC (DIFF if done locally), ANC, Sodium,
Potassium, Chloride, Carbon Dioxide, BUN, Creatinine, Glucose, Total Bilirubin, AST, ALT, Alkaline Phosphatase;
CHEMOTHERAPY ROOM APPOINTMENT: vinCRIStine, DACTINOmycin, mesna, cyclophosphamide for 150 minutes.
Day 8, Cycle 4 – Planned for 8/22/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Adjuvant); THERAPY: mesna 800 mg IV/PO prior to, 4 and 8 hours after each cyclophosphamide
dose; Cycle 1 through 4: vinCRISTine 1.5 mg/m2 IV (maximum dose for each treatment day = 2 mg) Day 1,8, and 15;
DACTINOmycin 45 mcg/kg IV (maximum dose for each treatment day = 2.5 mg) Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle
5: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 6:
vinCRISTine 1.5 mg/m2 IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 7: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 8: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 9 through 11: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 12: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 13 and 14: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; LENGTH: 21 days; COURSE: 14 cycles
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Ordered dose of 45 mcg/kg ONCE exceeds the recommended single dose limit of 2,500 mcg.
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Zztestonc,Jeff J [2507481]
6/13/2017 8:27:25 AM Page 16 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Verify pretreatment labs have been obtained: CBC, ANC.
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 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
vinCRIStine (ONCOVIN) 2.9 mg in sodium chloride 0.9 % 25 mL bag
2.9 mg (rounded from 2.94 mg = 1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3-5 Minutes
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
Follow-Up
Verify Appointments
Verify next day appointment(s) have been scheduled.
Day 15, Cycle 4 – Planned for 8/29/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Adjuvant); THERAPY: mesna 800 mg IV/PO prior to, 4 and 8 hours after each cyclophosphamide
dose; Cycle 1 through 4: vinCRISTine 1.5 mg/m2 IV (maximum dose for each treatment day = 2 mg) Day 1,8, and 15;
DACTINOmycin 45 mcg/kg IV (maximum dose for each treatment day = 2.5 mg) Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle
5: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 6:
vinCRISTine 1.5 mg/m2 IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 7: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 8: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 9 through 11: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 12: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 13 and 14: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; LENGTH: 21 days; COURSE: 14 cycles
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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Zztestonc,Jeff J [2507481]
6/13/2017 8:27:25 AM Page 17 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Verify pretreatment labs have been obtained: CBC, ANC.
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 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
vinCRIStine (ONCOVIN) 2.9 mg in sodium chloride 0.9 % 25 mL bag
2.9 mg (rounded from 2.94 mg = 1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3-5 Minutes
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
Follow-Up
Verify Appointments
Verify next day appointment(s) have been scheduled.
Cycle 5 – 9/5/2017 through 9/25/2017 (21 days), Planned
Day 1, Cycle 5 – Planned for 9/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Adjuvant); THERAPY: mesna 800 mg IV/PO prior to, 4 and 8 hours after each cyclophosphamide
dose; Cycle 1 through 4: vinCRISTine 1.5 mg/m2 IV (maximum dose for each treatment day = 2 mg) Day 1,8, and 15;
DACTINOmycin 45 mcg/kg IV (maximum dose for each treatment day = 2.5 mg) Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle
5: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 6:
vinCRISTine 1.5 mg/m2 IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 7: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 8: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 9 through 11: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 12: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 13 and 14: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; LENGTH: 21 days; COURSE: 14 cycles
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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Zztestonc,Jeff J [2507481]
6/13/2017 8:27:25 AM Page 18 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+7 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Platelets, Creatinine, Total Bilirubin
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than ULN or Total Bilirubin greater than ULN.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of, and for two days after cyclophosphamide
treatment.
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
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
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Zztestonc,Jeff J [2507481]
6/13/2017 8:27:25 AM Page 19 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to cyclophosphamide.
Treatment Medications
vinCRIStine (ONCOVIN) 2.9 mg in sodium chloride 0.9 % 25 mL bag
2.9 mg (rounded from 2.94 mg = 1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3-5 Minutes
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
DACTINOmycin (COSMOGEN) injection 3,600 mcg
3,600 mcg (45 mcg/kg × 80 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
IV push over 1-5 minutes into running IV. Max dose = 2500 mcg.
mesna (MESNEX) 800 mg in dextrose 5 % 50 mL bag
800 mg, Intravenous, ONCE, 1 dose Starting when released
Give prior to start of cyclophosphamide.
cyclophosphamide (CYTOXAN) 4,312 mg bag
4,312 mg (2,200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Treatment Medications (delete all that do not apply)
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): mesna oral at 4 hours and 8 hours after the
start of cyclophosphamide. (See Day 1 of Cycle 1)
mesna (MESNEX) 800 mg in dextrose 5 % 50 mL bag
800 mg, Intravenous, EVERY 4 HOURS, 2 doses Starting when released
Doses to be given 4 and 8 hours after cyclophosphamide. Omit if given PO
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC (DIFF if done locally), ANC, Sodium,
Potassium, Chloride, Carbon Dioxide, BUN, Creatinine, Glucose, Total Bilirubin, AST, ALT, Alkaline Phosphatase;
CHEMOTHERAPY ROOM APPOINTMENT: vinCRIStine, mesna, cyclophosphamide for 150 minutes.
Day 10 - Lab Only, Cycle 5 – Planned for 9/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Adjuvant); THERAPY: mesna 800 mg IV/PO prior to, 4 and 8 hours after each cyclophosphamide
dose; Cycle 1 through 4: vinCRISTine 1.5 mg/m2 IV (maximum dose for each treatment day = 2 mg) Day 1,8, and 15;
DACTINOmycin 45 mcg/kg IV (maximum dose for each treatment day = 2.5 mg) Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle
5: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 6:
vinCRISTine 1.5 mg/m2 IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 7: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 8: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 9 through 11: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 12: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 13 and 14: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; LENGTH: 21 days; COURSE: 14 cycles
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
Ordered dose of 45 mcg/kg ONCE exceeds the recommended single dose limit of 2,500 mcg.
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Zztestonc,Jeff J [2507481]
6/13/2017 8:27:25 AM Page 20 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Expected-S+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
Verify Appointments
Verify next day appointment(s) have been scheduled.
Cycle 6 – 9/26/2017 through 10/16/2017 (21 days), Planned
Day 1, Cycle 6 – Planned for 9/26/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Adjuvant); THERAPY: mesna 800 mg IV/PO prior to, 4 and 8 hours after each cyclophosphamide
dose; Cycle 1 through 4: vinCRISTine 1.5 mg/m2 IV (maximum dose for each treatment day = 2 mg) Day 1,8, and 15;
DACTINOmycin 45 mcg/kg IV (maximum dose for each treatment day = 2.5 mg) Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle
5: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 6:
vinCRISTine 1.5 mg/m2 IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 7: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 8: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 9 through 11: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 12: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 13 and 14: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; LENGTH: 21 days; COURSE: 14 cycles
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+21 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+21 Approximate, Expires-S+365, Routine
BUN
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
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Zztestonc,Jeff J [2507481]
6/13/2017 8:27:25 AM Page 21 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Verify pretreatment labs have been obtained: CBC, ANC, Platelets, Creatinine, Total Bilirubin
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than ULN or Total Bilirubin greater than ULN.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of, and for two days after cyclophosphamide
treatment.
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
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to cyclophosphamide.
Treatment Medications
vinCRIStine (ONCOVIN) 2.9 mg in sodium chloride 0.9 % 25 mL bag
2.9 mg (rounded from 2.94 mg = 1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3-5 Minutes
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
mesna (MESNEX) 800 mg in dextrose 5 % 50 mL bag
800 mg, Intravenous, ONCE, 1 dose Starting when released
Give prior to start of cyclophosphamide.
cyclophosphamide (CYTOXAN) 4,312 mg bag
4,312 mg (2,200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Treatment Medications (delete all that do not apply)
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): mesna oral at 4 hours and 8 hours after the
start of cyclophosphamide. (See Day 1 of Cycle 1)
mesna (MESNEX) 800 mg in dextrose 5 % 50 mL bag
800 mg, Intravenous, EVERY 4 HOURS, 2 doses Starting when released
Doses to be given 4 and 8 hours after cyclophosphamide. Omit if given PO
Follow-Up
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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Zztestonc,Jeff J [2507481]
6/13/2017 8:27:25 AM Page 22 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC (DIFF if done locally), ANC, Sodium,
Potassium, Chloride, Carbon Dioxide, BUN, Creatinine, Glucose, Total Bilirubin, AST, ALT, Alkaline Phosphatase;
CHEMOTHERAPY ROOM APPOINTMENT: vinCRIStine, mesna, cyclophosphamide for 150 minutes.
Day 10 - Lab Only, Cycle 6 – Planned for 10/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Adjuvant); THERAPY: mesna 800 mg IV/PO prior to, 4 and 8 hours after each cyclophosphamide
dose; Cycle 1 through 4: vinCRISTine 1.5 mg/m2 IV (maximum dose for each treatment day = 2 mg) Day 1,8, and 15;
DACTINOmycin 45 mcg/kg IV (maximum dose for each treatment day = 2.5 mg) Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle
5: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 6:
vinCRISTine 1.5 mg/m2 IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 7: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 8: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 9 through 11: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 12: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 13 and 14: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; LENGTH: 21 days; COURSE: 14 cycles
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
Verify Appointments
Verify next day appointment(s) have been scheduled.
Cycle 7 – 10/17/2017 through 11/6/2017 (21 days), Planned
Day 1, Cycle 7 – Planned for 10/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Adjuvant); THERAPY: mesna 800 mg IV/PO prior to, 4 and 8 hours after each cyclophosphamide
dose; Cycle 1 through 4: vinCRISTine 1.5 mg/m2 IV (maximum dose for each treatment day = 2 mg) Day 1,8, and 15;
DACTINOmycin 45 mcg/kg IV (maximum dose for each treatment day = 2.5 mg) Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle
5: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 6:
vinCRISTine 1.5 mg/m2 IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 7: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 8: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 9 through 11: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 12: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 13 and 14: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; LENGTH: 21 days; COURSE: 14 cycles
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Jeff J [2507481]
6/13/2017 8:27:25 AM Page 23 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+21 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+21 Approximate, Expires-S+365, Routine
BUN
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Platelets, Creatinine, Total Bilirubin
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than ULN or Total Bilirubin greater than ULN.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of, and for two days after cyclophosphamide
treatment.
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
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
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Zztestonc,Jeff J [2507481]
6/13/2017 8:27:25 AM Page 24 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to cyclophosphamide.
Treatment Medications
vinCRIStine (ONCOVIN) 2.9 mg in sodium chloride 0.9 % 25 mL bag
2.9 mg (rounded from 2.94 mg = 1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3-5 Minutes
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
mesna (MESNEX) 800 mg in dextrose 5 % 50 mL bag
800 mg, Intravenous, ONCE, 1 dose Starting when released
Give prior to start of cyclophosphamide.
cyclophosphamide (CYTOXAN) 4,312 mg bag
4,312 mg (2,200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Treatment Medications (delete all that do not apply)
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): mesna oral at 4 hours and 8 hours after the
start of cyclophosphamide. (See Day 1 of Cycle 1)
mesna (MESNEX) 800 mg in dextrose 5 % 50 mL bag
800 mg, Intravenous, EVERY 4 HOURS, 2 doses Starting when released
Doses to be given 4 and 8 hours after cyclophosphamide. Omit if given PO
Follow-Up
DAY 8 FOLLOW-UP
RETURN TO CLINIC; LABS: CBC (DIFF if done locally), ANC; CHEMOTHERAPY ROOM APPOINTMENT: vinCRISTine for 30
minutes.
DAY 15 FOLLOW-UP
RETURN TO CLINIC; LABS: CBC (DIFF if done locally), ANC; CHEMOTHERAPY ROOM APPOINTMENT: vinCRISTine for 30
minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC (DIFF if done locally), ANC, Sodium,
Potassium, Chloride, Carbon Dioxide, BUN, Creatinine, Glucose, Total Bilirubin, AST, ALT, Alkaline Phosphatase;
CHEMOTHERAPY ROOM APPOINTMENT: vinCRIStine, DACTINOmycin, mesna, cyclophosphamide for 150 minutes.
Day 8, Cycle 7 – Planned for 10/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Adjuvant); THERAPY: mesna 800 mg IV/PO prior to, 4 and 8 hours after each cyclophosphamide
dose; Cycle 1 through 4: vinCRISTine 1.5 mg/m2 IV (maximum dose for each treatment day = 2 mg) Day 1,8, and 15;
DACTINOmycin 45 mcg/kg IV (maximum dose for each treatment day = 2.5 mg) Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle
5: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 6:
vinCRISTine 1.5 mg/m2 IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 7: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 8: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 9 through 11: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 12: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 13 and 14: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; LENGTH: 21 days; COURSE: 14 cycles
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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Zztestonc,Jeff J [2507481]
6/13/2017 8:27:25 AM Page 25 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
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 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
vinCRIStine (ONCOVIN) 2.9 mg in sodium chloride 0.9 % 25 mL bag
2.9 mg (rounded from 2.94 mg = 1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3-5 Minutes
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
Follow-Up
Verify Appointments
Verify next day appointment(s) have been scheduled.
Day 15, Cycle 7 – Planned for 10/31/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Adjuvant); THERAPY: mesna 800 mg IV/PO prior to, 4 and 8 hours after each cyclophosphamide
dose; Cycle 1 through 4: vinCRISTine 1.5 mg/m2 IV (maximum dose for each treatment day = 2 mg) Day 1,8, and 15;
DACTINOmycin 45 mcg/kg IV (maximum dose for each treatment day = 2.5 mg) Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle
5: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 6:
vinCRISTine 1.5 mg/m2 IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 7: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 8: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 9 through 11: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 12: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 13 and 14: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; LENGTH: 21 days; COURSE: 14 cycles
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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Zztestonc,Jeff J [2507481]
6/13/2017 8:27:25 AM Page 26 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
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 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
vinCRIStine (ONCOVIN) 2.9 mg in sodium chloride 0.9 % 25 mL bag
2.9 mg (rounded from 2.94 mg = 1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3-5 Minutes
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
Follow-Up
Verify Appointments
Verify next day appointment(s) have been scheduled.
Cycle 8 – 11/7/2017 through 11/27/2017 (21 days), Planned
Day 1, Cycle 8 – Planned for 11/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Adjuvant); THERAPY: mesna 800 mg IV/PO prior to, 4 and 8 hours after each cyclophosphamide
dose; Cycle 1 through 4: vinCRISTine 1.5 mg/m2 IV (maximum dose for each treatment day = 2 mg) Day 1,8, and 15;
DACTINOmycin 45 mcg/kg IV (maximum dose for each treatment day = 2.5 mg) Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle
5: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 6:
vinCRISTine 1.5 mg/m2 IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 7: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 8: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 9 through 11: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 12: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 13 and 14: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; LENGTH: 21 days; COURSE: 14 cycles
Consent
Verify Consent
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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Zztestonc,Jeff J [2507481]
6/13/2017 8:27:25 AM Page 27 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+7 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Platelets, Creatinine, Total Bilirubin
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than ULN or Total Bilirubin greater than ULN.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of, and for two days after cyclophosphamide
treatment.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
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Zztestonc,Jeff J [2507481]
6/13/2017 8:27:25 AM Page 28 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to cyclophosphamide.
Treatment Medications
vinCRIStine (ONCOVIN) 2.9 mg in sodium chloride 0.9 % 25 mL bag
2.9 mg (rounded from 2.94 mg = 1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3-5 Minutes
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
DACTINOmycin (COSMOGEN) injection 3,600 mcg
3,600 mcg (45 mcg/kg × 80 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
IV push over 1-5 minutes into running IV. Max dose = 2500 mcg.
mesna (MESNEX) 800 mg in dextrose 5 % 50 mL bag
800 mg, Intravenous, ONCE, 1 dose Starting when released
Give prior to start of cyclophosphamide.
cyclophosphamide (CYTOXAN) 4,312 mg bag
4,312 mg (2,200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Treatment Medications (delete all that do not apply)
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): mesna oral at 4 hours and 8 hours after the
start of cyclophosphamide. (See Day 1 of Cycle 1)
mesna (MESNEX) 800 mg in dextrose 5 % 50 mL bag
800 mg, Intravenous, EVERY 4 HOURS, 2 doses Starting when released
Doses to be given 4 and 8 hours after cyclophosphamide. Omit if given PO
Follow-Up
DAY 8 FOLLOW-UP
RETURN TO CLINIC; LABS: CBC (DIFF if done locally), ANC; CHEMOTHERAPY ROOM APPOINTMENT: vinCRISTine for 30
minutes.
DAY 15 FOLLOW-UP
RETURN TO CLINIC; LABS: CBC (DIFF if done locally), ANC; CHEMOTHERAPY ROOM APPOINTMENT: vinCRISTine for 30
minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC (DIFF if done locally), ANC, Sodium,
Potassium, Chloride, Carbon Dioxide, BUN, Creatinine, Glucose, Total Bilirubin, AST, ALT, Alkaline Phosphatase;
CHEMOTHERAPY ROOM APPOINTMENT: vinCRIStine, DACTINOmycin, mesna, cyclophosphamide for 150 minutes.
Day 8, Cycle 8 – Planned for 11/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Adjuvant); THERAPY: mesna 800 mg IV/PO prior to, 4 and 8 hours after each cyclophosphamide
dose; Cycle 1 through 4: vinCRISTine 1.5 mg/m2 IV (maximum dose for each treatment day = 2 mg) Day 1,8, and 15;
DACTINOmycin 45 mcg/kg IV (maximum dose for each treatment day = 2.5 mg) Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle
5: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 6:
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
Ordered dose of 45 mcg/kg ONCE exceeds the recommended single dose limit of 2,500 mcg.
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Zztestonc,Jeff J [2507481]
6/13/2017 8:27:25 AM Page 29 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

vinCRISTine 1.5 mg/m2 IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 7: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 8: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 9 through 11: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 12: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 13 and 14: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; LENGTH: 21 days; COURSE: 14 cycles
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
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 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
vinCRIStine (ONCOVIN) 2.9 mg in sodium chloride 0.9 % 25 mL bag
2.9 mg (rounded from 2.94 mg = 1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3-5 Minutes
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
Follow-Up
Verify Appointments
Verify next day appointment(s) have been scheduled.
Day 15, Cycle 8 – Planned for 11/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Adjuvant); THERAPY: mesna 800 mg IV/PO prior to, 4 and 8 hours after each cyclophosphamide
dose; Cycle 1 through 4: vinCRISTine 1.5 mg/m2 IV (maximum dose for each treatment day = 2 mg) Day 1,8, and 15;
DACTINOmycin 45 mcg/kg IV (maximum dose for each treatment day = 2.5 mg) Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle
5: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 6:
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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Zztestonc,Jeff J [2507481]
6/13/2017 8:27:25 AM Page 30 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

vinCRISTine 1.5 mg/m2 IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 7: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 8: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 9 through 11: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 12: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 13 and 14: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; LENGTH: 21 days; COURSE: 14 cycles
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
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 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
vinCRIStine (ONCOVIN) 2.9 mg in sodium chloride 0.9 % 25 mL bag
2.9 mg (rounded from 2.94 mg = 1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3-5 Minutes
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
Follow-Up
Verify Appointments
Verify next day appointment(s) have been scheduled.
Cycle 9 – 11/28/2017 through 12/18/2017 (21 days), Planned
Day 1, Cycle 9 – Planned for 11/28/2017
Treatment Plan Information
Treatment Plan Summary
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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Zztestonc,Jeff J [2507481]
6/13/2017 8:27:25 AM Page 31 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

DISEASE: Rhabdomyosarcoma (Adjuvant); THERAPY: mesna 800 mg IV/PO prior to, 4 and 8 hours after each cyclophosphamide
dose; Cycle 1 through 4: vinCRISTine 1.5 mg/m2 IV (maximum dose for each treatment day = 2 mg) Day 1,8, and 15;
DACTINOmycin 45 mcg/kg IV (maximum dose for each treatment day = 2.5 mg) Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle
5: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 6:
vinCRISTine 1.5 mg/m2 IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 7: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 8: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 9 through 11: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 12: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 13 and 14: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; LENGTH: 21 days; COURSE: 14 cycles
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+7 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Platelets, Creatinine, Total Bilirubin
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than ULN or Total Bilirubin greater than ULN.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of, and for two days after cyclophosphamide
treatment.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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Zztestonc,Jeff J [2507481]
6/13/2017 8:27:25 AM Page 32 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to cyclophosphamide.
Treatment Medications
vinCRIStine (ONCOVIN) 2.9 mg in sodium chloride 0.9 % 25 mL bag
2.9 mg (rounded from 2.94 mg = 1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3-5 Minutes
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
DACTINOmycin (COSMOGEN) injection 3,600 mcg
3,600 mcg (45 mcg/kg × 80 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
IV push over 1-5 minutes into running IV. Max dose = 2500 mcg.
mesna (MESNEX) 800 mg in dextrose 5 % 50 mL bag
800 mg, Intravenous, ONCE, 1 dose Starting when released
Give prior to start of cyclophosphamide.
cyclophosphamide (CYTOXAN) 4,312 mg bag
4,312 mg (2,200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Treatment Medications (delete all that do not apply)
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): mesna oral at 4 hours and 8 hours after the
start of cyclophosphamide. (See Day 1 of Cycle 1)
mesna (MESNEX) 800 mg in dextrose 5 % 50 mL bag
800 mg, Intravenous, EVERY 4 HOURS, 2 doses Starting when released
Doses to be given 4 and 8 hours after cyclophosphamide. Omit if given PO
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC (DIFF if done locally), ANC, Sodium,
Potassium, Chloride, Carbon Dioxide, BUN, Creatinine, Glucose, Total Bilirubin, AST, ALT, Alkaline Phosphatase;
CHEMOTHERAPY ROOM APPOINTMENT: vinCRIStine, DACTINOmycin, mesna, cyclophosphamide for 150 minutes.
Day 10 - Lab Only, Cycle 9 – Planned for 12/7/2017
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
Ordered dose of 45 mcg/kg ONCE exceeds the recommended single dose limit of 2,500 mcg.
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Zztestonc,Jeff J [2507481]
6/13/2017 8:27:25 AM Page 33 of 49
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: Rhabdomyosarcoma (Adjuvant); THERAPY: mesna 800 mg IV/PO prior to, 4 and 8 hours after each cyclophosphamide
dose; Cycle 1 through 4: vinCRISTine 1.5 mg/m2 IV (maximum dose for each treatment day = 2 mg) Day 1,8, and 15;
DACTINOmycin 45 mcg/kg IV (maximum dose for each treatment day = 2.5 mg) Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle
5: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 6:
vinCRISTine 1.5 mg/m2 IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 7: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 8: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 9 through 11: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 12: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 13 and 14: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; LENGTH: 21 days; COURSE: 14 cycles
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
Verify Appointments
Verify next day appointment(s) have been scheduled.
Cycle 10 – 12/19/2017 through 1/8/2018 (21 days), Planned
Day 1, Cycle 10 – Planned for 12/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Adjuvant); THERAPY: mesna 800 mg IV/PO prior to, 4 and 8 hours after each cyclophosphamide
dose; Cycle 1 through 4: vinCRISTine 1.5 mg/m2 IV (maximum dose for each treatment day = 2 mg) Day 1,8, and 15;
DACTINOmycin 45 mcg/kg IV (maximum dose for each treatment day = 2.5 mg) Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle
5: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 6:
vinCRISTine 1.5 mg/m2 IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 7: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 8: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 9 through 11: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 12: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 13 and 14: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; LENGTH: 21 days; COURSE: 14 cycles
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
ELECTROLYTES
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Zztestonc,Jeff J [2507481]
6/13/2017 8:27:25 AM Page 34 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Expected-S+7 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+7 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Platelets, Creatinine, Total Bilirubin
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than ULN or Total Bilirubin greater than ULN.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of, and for two days after cyclophosphamide
treatment.
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
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to cyclophosphamide.
Treatment Medications
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Zztestonc,Jeff J [2507481]
6/13/2017 8:27:25 AM Page 35 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

vinCRIStine (ONCOVIN) 2.9 mg in sodium chloride 0.9 % 25 mL bag
2.9 mg (rounded from 2.94 mg = 1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released, Administer over 3-5 Minutes
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
DACTINOmycin (COSMOGEN) injection 3,600 mcg
3,600 mcg (45 mcg/kg × 80 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
IV push over 1-5 minutes into running IV. Max dose = 2500 mcg.
mesna (MESNEX) 800 mg in dextrose 5 % 50 mL bag
800 mg, Intravenous, ONCE, 1 dose Starting when released
Give prior to start of cyclophosphamide.
cyclophosphamide (CYTOXAN) 4,312 mg bag
4,312 mg (2,200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Treatment Medications (delete all that do not apply)
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): mesna oral at 4 hours and 8 hours after the
start of cyclophosphamide. (See Day 1 of Cycle 1)
mesna (MESNEX) 800 mg in dextrose 5 % 50 mL bag
800 mg, Intravenous, EVERY 4 HOURS, 2 doses Starting when released
Doses to be given 4 and 8 hours after cyclophosphamide. Omit if given PO
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC (DIFF if done locally), ANC, Sodium,
Potassium, Chloride, Carbon Dioxide, BUN, Creatinine, Glucose, Total Bilirubin, AST, ALT, Alkaline Phosphatase;
CHEMOTHERAPY ROOM APPOINTMENT: vinCRIStine, DACTINOmycin, mesna, cyclophosphamide for 150 minutes.
Day 10 - Lab Only, Cycle 10 – Planned for 12/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Adjuvant); THERAPY: mesna 800 mg IV/PO prior to, 4 and 8 hours after each cyclophosphamide
dose; Cycle 1 through 4: vinCRISTine 1.5 mg/m2 IV (maximum dose for each treatment day = 2 mg) Day 1,8, and 15;
DACTINOmycin 45 mcg/kg IV (maximum dose for each treatment day = 2.5 mg) Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle
5: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 6:
vinCRISTine 1.5 mg/m2 IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 7: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 8: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 9 through 11: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 12: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 13 and 14: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; LENGTH: 21 days; COURSE: 14 cycles
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
Ordered dose of 45 mcg/kg ONCE exceeds the recommended single dose limit of 2,500 mcg.
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Zztestonc,Jeff J [2507481]
6/13/2017 8:27:25 AM Page 36 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Verify Appointments
Verify next day appointment(s) have been scheduled.
Cycle 11 – 1/9/2018 through 1/29/2018 (21 days), Planned
Day 1, Cycle 11 – Planned for 1/9/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Adjuvant); THERAPY: mesna 800 mg IV/PO prior to, 4 and 8 hours after each cyclophosphamide
dose; Cycle 1 through 4: vinCRISTine 1.5 mg/m2 IV (maximum dose for each treatment day = 2 mg) Day 1,8, and 15;
DACTINOmycin 45 mcg/kg IV (maximum dose for each treatment day = 2.5 mg) Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle
5: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 6:
vinCRISTine 1.5 mg/m2 IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 7: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 8: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 9 through 11: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 12: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 13 and 14: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; LENGTH: 21 days; COURSE: 14 cycles
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+7 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Platelets, Creatinine, Total Bilirubin
Treatment Parameters
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Zztestonc,Jeff J [2507481]
6/13/2017 8:27:25 AM Page 37 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than ULN or Total Bilirubin greater than ULN.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of, and for two days after cyclophosphamide
treatment.
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
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to cyclophosphamide.
Treatment Medications
vinCRIStine (ONCOVIN) 2.9 mg in sodium chloride 0.9 % 25 mL bag
2.9 mg (rounded from 2.94 mg = 1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3-5 Minutes
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
DACTINOmycin (COSMOGEN) injection 3,600 mcg
3,600 mcg (45 mcg/kg × 80 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
IV push over 1-5 minutes into running IV. Max dose = 2500 mcg.
mesna (MESNEX) 800 mg in dextrose 5 % 50 mL bag
800 mg, Intravenous, ONCE, 1 dose Starting when released
Give prior to start of cyclophosphamide.
cyclophosphamide (CYTOXAN) 4,312 mg bag
4,312 mg (2,200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Treatment Medications (delete all that do not apply)
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): mesna oral at 4 hours and 8 hours after the
start of cyclophosphamide. (See Day 1 of Cycle 1)
mesna (MESNEX) 800 mg in dextrose 5 % 50 mL bag
800 mg, Intravenous, EVERY 4 HOURS, 2 doses Starting when released
Doses to be given 4 and 8 hours after cyclophosphamide. Omit if given PO
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
Ordered dose of 45 mcg/kg ONCE exceeds the recommended single dose limit of 2,500 mcg.
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Zztestonc,Jeff J [2507481]
6/13/2017 8:27:25 AM Page 38 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC (DIFF if done locally), ANC, Sodium,
Potassium, Chloride, Carbon Dioxide, BUN, Creatinine, Glucose, Total Bilirubin, AST, ALT, Alkaline Phosphatase;
CHEMOTHERAPY ROOM APPOINTMENT: vinCRIStine, DACTINOmycin, mesna, cyclophosphamide for 150 minutes.
Day 10 - Lab Only, Cycle 11 – Planned for 1/18/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Adjuvant); THERAPY: mesna 800 mg IV/PO prior to, 4 and 8 hours after each cyclophosphamide
dose; Cycle 1 through 4: vinCRISTine 1.5 mg/m2 IV (maximum dose for each treatment day = 2 mg) Day 1,8, and 15;
DACTINOmycin 45 mcg/kg IV (maximum dose for each treatment day = 2.5 mg) Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle
5: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 6:
vinCRISTine 1.5 mg/m2 IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 7: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 8: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 9 through 11: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 12: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 13 and 14: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; LENGTH: 21 days; COURSE: 14 cycles
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
Verify Appointments
Verify next day appointment(s) have been scheduled.
Cycle 12 – 1/30/2018 through 2/19/2018 (21 days), Planned
Day 1, Cycle 12 – Planned for 1/30/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Adjuvant); THERAPY: mesna 800 mg IV/PO prior to, 4 and 8 hours after each cyclophosphamide
dose; Cycle 1 through 4: vinCRISTine 1.5 mg/m2 IV (maximum dose for each treatment day = 2 mg) Day 1,8, and 15;
DACTINOmycin 45 mcg/kg IV (maximum dose for each treatment day = 2.5 mg) Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle
5: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 6:
vinCRISTine 1.5 mg/m2 IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 7: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 8: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 9 through 11: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 12: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 13 and 14: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; LENGTH: 21 days; COURSE: 14 cycles
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Jeff J [2507481]
6/13/2017 8:27:25 AM Page 39 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+21 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+21 Approximate, Expires-S+365, Routine
BUN
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Platelets, Creatinine, Total Bilirubin
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than ULN or Total Bilirubin greater than ULN.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of, and for two days after cyclophosphamide
treatment.
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
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
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Zztestonc,Jeff J [2507481]
6/13/2017 8:27:25 AM Page 40 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to cyclophosphamide.
Treatment Medications
vinCRIStine (ONCOVIN) 2.9 mg in sodium chloride 0.9 % 25 mL bag
2.9 mg (rounded from 2.94 mg = 1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3-5 Minutes
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
DACTINOmycin (COSMOGEN) injection 3,600 mcg
3,600 mcg (45 mcg/kg × 80 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
IV push over 1-5 minutes into running IV. Max dose = 2500 mcg.
mesna (MESNEX) 800 mg in dextrose 5 % 50 mL bag
800 mg, Intravenous, ONCE, 1 dose Starting when released
Give prior to start of cyclophosphamide.
cyclophosphamide (CYTOXAN) 4,312 mg bag
4,312 mg (2,200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Treatment Medications (delete all that do not apply)
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): mesna oral at 4 hours and 8 hours after the
start of cyclophosphamide. (See Day 1 of Cycle 1)
mesna (MESNEX) 800 mg in dextrose 5 % 50 mL bag
800 mg, Intravenous, EVERY 4 HOURS, 2 doses Starting when released
Doses to be given 4 and 8 hours after cyclophosphamide. Omit if given PO
Follow-Up
DAY 8 FOLLOW-UP
RETURN TO CLINIC; LABS: CBC (DIFF if done locally), ANC; CHEMOTHERAPY ROOM APPOINTMENT: vinCRISTine for 30
minutes.
DAY 15 FOLLOW-UP
RETURN TO CLINIC; LABS: CBC (DIFF if done locally), ANC; CHEMOTHERAPY ROOM APPOINTMENT: vinCRISTine for 30
minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC (DIFF if done locally), ANC, Sodium,
Potassium, Chloride, Carbon Dioxide, BUN, Creatinine, Glucose, Total Bilirubin, AST, ALT, Alkaline Phosphatase;
CHEMOTHERAPY ROOM APPOINTMENT: vinCRIStine, DACTINOmycin, mesna, cyclophosphamide for 150 minutes.
Day 8, Cycle 12 – Planned for 2/6/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Adjuvant); THERAPY: mesna 800 mg IV/PO prior to, 4 and 8 hours after each cyclophosphamide
dose; Cycle 1 through 4: vinCRISTine 1.5 mg/m2 IV (maximum dose for each treatment day = 2 mg) Day 1,8, and 15;
DACTINOmycin 45 mcg/kg IV (maximum dose for each treatment day = 2.5 mg) Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle
5: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 6:
vinCRISTine 1.5 mg/m2 IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 7: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 8: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 9 through 11: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 12: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 13 and 14: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; LENGTH: 21 days; COURSE: 14 cycles
IV Access
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
Ordered dose of 45 mcg/kg ONCE exceeds the recommended single dose limit of 2,500 mcg.
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Zztestonc,Jeff J [2507481]
6/13/2017 8:27:25 AM Page 41 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of, and for two days after cyclophosphamide
treatment.
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 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
vinCRIStine (ONCOVIN) 2.9 mg in sodium chloride 0.9 % 25 mL bag
2.9 mg (rounded from 2.94 mg = 1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3-5 Minutes
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
Follow-Up
Verify Appointments
Verify next day appointment(s) have been scheduled.
Day 15, Cycle 12 – Planned for 2/13/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Adjuvant); THERAPY: mesna 800 mg IV/PO prior to, 4 and 8 hours after each cyclophosphamide
dose; Cycle 1 through 4: vinCRISTine 1.5 mg/m2 IV (maximum dose for each treatment day = 2 mg) Day 1,8, and 15;
DACTINOmycin 45 mcg/kg IV (maximum dose for each treatment day = 2.5 mg) Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle
5: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 6:
vinCRISTine 1.5 mg/m2 IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 7: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 8: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 9 through 11: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 12: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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Zztestonc,Jeff J [2507481]
6/13/2017 8:27:25 AM Page 42 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 13 and 14: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; LENGTH: 21 days; COURSE: 14 cycles
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of, and for two days after cyclophosphamide
treatment.
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 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
vinCRIStine (ONCOVIN) 2.9 mg in sodium chloride 0.9 % 25 mL bag
2.9 mg (rounded from 2.94 mg = 1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3-5 Minutes
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
Follow-Up
Verify Appointments
Verify next day appointment(s) have been scheduled.
Cycle 13 – 2/20/2018 through 3/12/2018 (21 days), Planned
Day 1, Cycle 13 – Planned for 2/20/2018
Treatment Plan Information
Treatment Plan Summary
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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Zztestonc,Jeff J [2507481]
6/13/2017 8:27:25 AM Page 43 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

DISEASE: Rhabdomyosarcoma (Adjuvant); THERAPY: mesna 800 mg IV/PO prior to, 4 and 8 hours after each cyclophosphamide
dose; Cycle 1 through 4: vinCRISTine 1.5 mg/m2 IV (maximum dose for each treatment day = 2 mg) Day 1,8, and 15;
DACTINOmycin 45 mcg/kg IV (maximum dose for each treatment day = 2.5 mg) Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle
5: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 6:
vinCRISTine 1.5 mg/m2 IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 7: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 8: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 9 through 11: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 12: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 13 and 14: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; LENGTH: 21 days; COURSE: 14 cycles
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+7 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Platelets, Creatinine, Total Bilirubin
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than ULN or Total Bilirubin greater than ULN.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of, and for two days after cyclophosphamide
treatment.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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Zztestonc,Jeff J [2507481]
6/13/2017 8:27:25 AM Page 44 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to cyclophosphamide.
Treatment Medications
vinCRIStine (ONCOVIN) 2.9 mg in sodium chloride 0.9 % 25 mL bag
2.9 mg (rounded from 2.94 mg = 1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3-5 Minutes
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
DACTINOmycin (COSMOGEN) injection 3,600 mcg
3,600 mcg (45 mcg/kg × 80 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
IV push over 1-5 minutes into running IV. Max dose = 2500 mcg.
mesna (MESNEX) 800 mg in dextrose 5 % 50 mL bag
800 mg, Intravenous, ONCE, 1 dose Starting when released
Give prior to start of cyclophosphamide.
cyclophosphamide (CYTOXAN) 4,312 mg bag
4,312 mg (2,200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Treatment Medications (delete all that do not apply)
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): mesna oral at 4 hours and 8 hours after the
start of cyclophosphamide. (See Day 1 of Cycle 1)
mesna (MESNEX) 800 mg in dextrose 5 % 50 mL bag
800 mg, Intravenous, EVERY 4 HOURS, 2 doses Starting when released
Doses to be given 4 and 8 hours after cyclophosphamide. Omit if given PO
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC (DIFF if done locally), ANC, Sodium,
Potassium, Chloride, Carbon Dioxide, BUN, Creatinine, Glucose, Total Bilirubin, AST, ALT, Alkaline Phosphatase;
CHEMOTHERAPY ROOM APPOINTMENT: vinCRIStine, DACTINOmycin, mesna, cyclophosphamide for 150 minutes.
Day 10 - Lab Only, Cycle 13 – Planned for 3/1/2018
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
Ordered dose of 45 mcg/kg ONCE exceeds the recommended single dose limit of 2,500 mcg.
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Zztestonc,Jeff J [2507481]
6/13/2017 8:27:25 AM Page 45 of 49
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: Rhabdomyosarcoma (Adjuvant); THERAPY: mesna 800 mg IV/PO prior to, 4 and 8 hours after each cyclophosphamide
dose; Cycle 1 through 4: vinCRISTine 1.5 mg/m2 IV (maximum dose for each treatment day = 2 mg) Day 1,8, and 15;
DACTINOmycin 45 mcg/kg IV (maximum dose for each treatment day = 2.5 mg) Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle
5: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 6:
vinCRISTine 1.5 mg/m2 IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 7: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 8: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 9 through 11: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 12: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 13 and 14: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; LENGTH: 21 days; COURSE: 14 cycles
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
Verify Appointments
Verify next day appointment(s) have been scheduled.
Cycle 14 – 3/13/2018 through 4/2/2018 (21 days), Planned
Day 1, Cycle 14 – Planned for 3/13/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Adjuvant); THERAPY: mesna 800 mg IV/PO prior to, 4 and 8 hours after each cyclophosphamide
dose; Cycle 1 through 4: vinCRISTine 1.5 mg/m2 IV (maximum dose for each treatment day = 2 mg) Day 1,8, and 15;
DACTINOmycin 45 mcg/kg IV (maximum dose for each treatment day = 2.5 mg) Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle
5: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 6:
vinCRISTine 1.5 mg/m2 IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 7: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 8: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 9 through 11: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 12: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 13 and 14: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; LENGTH: 21 days; COURSE: 14 cycles
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
ELECTROLYTES
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Zztestonc,Jeff J [2507481]
6/13/2017 8:27:25 AM Page 46 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Expected-S+7 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+7 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Platelets, Creatinine, Total Bilirubin
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than ULN or Total Bilirubin greater than ULN.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of, and for two days after cyclophosphamide
treatment.
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
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to cyclophosphamide.
Treatment Medications
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Zztestonc,Jeff J [2507481]
6/13/2017 8:27:25 AM Page 47 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

vinCRIStine (ONCOVIN) 2.9 mg in sodium chloride 0.9 % 25 mL bag
2.9 mg (rounded from 2.94 mg = 1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released, Administer over 3-5 Minutes
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
DACTINOmycin (COSMOGEN) injection 3,600 mcg
3,600 mcg (45 mcg/kg × 80 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
IV push over 1-5 minutes into running IV. Max dose = 2500 mcg.
mesna (MESNEX) 800 mg in dextrose 5 % 50 mL bag
800 mg, Intravenous, ONCE, 1 dose Starting when released
Give prior to start of cyclophosphamide.
cyclophosphamide (CYTOXAN) 4,312 mg bag
4,312 mg (2,200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Treatment Medications (delete all that do not apply)
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): mesna oral at 4 hours and 8 hours after the
start of cyclophosphamide. (See Day 1 of Cycle 1)
mesna (MESNEX) 800 mg in dextrose 5 % 50 mL bag
800 mg, Intravenous, EVERY 4 HOURS, 2 doses Starting when released
Doses to be given 4 and 8 hours after cyclophosphamide. Omit if given PO
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC (DIFF if done locally), ANC, Sodium,
Potassium, Chloride, Carbon Dioxide, BUN, Creatinine, Glucose, Total Bilirubin, AST, ALT, Alkaline Phosphatase;
CHEMOTHERAPY ROOM APPOINTMENT: vinCRIStine, DACTINOmycin, mesna, cyclophosphamide for 150 minutes.
Day 10 - Lab Only, Cycle 14 – Planned for 3/22/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Adjuvant); THERAPY: mesna 800 mg IV/PO prior to, 4 and 8 hours after each cyclophosphamide
dose; Cycle 1 through 4: vinCRISTine 1.5 mg/m2 IV (maximum dose for each treatment day = 2 mg) Day 1,8, and 15;
DACTINOmycin 45 mcg/kg IV (maximum dose for each treatment day = 2.5 mg) Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle
5: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 6:
vinCRISTine 1.5 mg/m2 IV Day 1; cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 7: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 8: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 9 through 11: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 12: vinCRISTine 1.5 mg/m2 IV Day 1,8, and 15; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; Cycle 13 and 14: vinCRISTine 1.5 mg/m2 IV Day 1; DACTINOmycin 45 mcg/kg IV Day 1;
cyclophosphamide 2.2 g/m2 IV Day 1; LENGTH: 21 days; COURSE: 14 cycles
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
Ordered dose of 45 mcg/kg ONCE exceeds the recommended single dose limit of 2,500 mcg.
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Zztestonc,Jeff J [2507481]
6/13/2017 8:27:25 AM Page 48 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Verify Appointments
Verify next day appointment(s) have been scheduled.
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 8:27:25 AM Page 49 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org