/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/beacon-protocols/,/clinical/cckm-tools/content/beacon-protocols/sarcoma/,

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201706165

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UWHC,UWMF,

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

CSC Sarcoma Cyclophosphamide(21D:1) Dactinomycin(21D:1) Vincristine(21D:1) VER 5-1-17 (HL 967)

CSC Sarcoma Cyclophosphamide(21D:1) Dactinomycin(21D:1) Vincristine(21D:1) VER 5-1-17 (HL 967) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Sarcoma


CSC SARCOMA CYCLOPHOSPHAMIDE(21D1)DACTINOMYCIN(21D1)VINCRISTINE(21D1) VER 5-1-17 (HL 967( – 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: Ewing's sarcoma, Primitive neuroectodermal tumor of bone, Peripheral sarcoma of bone (Advanced); THERAPY:
DACTINOmycin 1.25 mg/m2 IV Day 1 (max dose = 2.5 mg), vinCRIStine 2 mg/m2 (max dose = 2 mg) IV Day 1, cyclophosphamide
1200 mg/m2 IV Day 1, mesna 400 mg/m2 IV prior to cyclophosphamide and 400 mg/m2 by mouth at 4 hours and 8 hours after start
of cyclophosphamide Day 1; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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
ALKALINE PHOSPHATASE
Expected-S Approximate, Expires-S+365, Routine
URINALYSIS WITH MICROSCOPY
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 two days following chemotherapy., 80 mg, Disp-2 cap, R-5, 1 X DAILY starting S,
Local Printer
dexamethasone (DECADRON) 4 MG tab
Take 2 tabs by mouth one time daily. Take for 3 days following chemotherapy, 8 mg, Disp-24 tab, R-5, 1 X DAILY starting S, Local
Printer
prochlorperazine (COMPAZINE) 10 MG tab
Take 1 tab by mouth every 6 hours as needed for nausea/vomiting., 10 mg, Disp-30 tab, R-5, EVERY 6 HOURS PRN starting S,
Local Printer
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth 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)
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Zztestonc,Jeff J [2507481]
6/13/2017 10:08:55 AM Page 1 of 18
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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: Grier HE, et al. N Engl J Med 2003;348:694-701.
Reference Information (2)
SARCOMA: Bernstein ML, et al. J Clin Oncol 2006;24:152-9.
Treatment Plan Summary
DISEASE: Ewing's sarcoma, Primitive neuroectodermal tumor of bone, Peripheral sarcoma of bone (Advanced); THERAPY:
DACTINOmycin 1.25 mg/m2 IV Day 1 (max dose = 2.5 mg), vinCRIStine 2 mg/m2 (max dose = 2 mg) IV Day 1, cyclophosphamide
1200 mg/m2 IV Day 1, mesna 400 mg/m2 IV prior to cyclophosphamide and 400 mg/m2 by mouth at 4 hours and 8 hours after start
of cyclophosphamide Day 1; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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 and resulted: CBC, ANC, Urine Heme.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1500/µL or Platelets less than or equal to 100K/µL or Urine
Hemoglobin greater than Trace.
Nursing Procedure, Assessment and Monitoring
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
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 10:08:55 AM Page 2 of 18
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
Treatment Medications
DACTINOmycin (COSMOGEN) injection 2,450 mcg
2,450 mcg (1.25 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
IV push over 1-5 minutes into running IV. Max dose = 2.5 mg
vinCRIStine (ONCOVIN) 3.9 mg in sodium chloride 0.9 % 25 mL bag
3.9 mg (rounded from 3.92 mg = 2 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) 784 mg in sodium chloride 0.9 % 50 mL bag
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give just prior to cyclophosphamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of
cyclophosphamide.
cyclophosphamide (CYTOXAN) 2,352 mg in sodium chloride 0.9 % 250 mL bag
2,352 mg (1,200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes.
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 (rounded from 784 mg = 400
mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-5, 2 X DAILY starting S
MD may delete this order and order IV mesna.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally)
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, Alkaline Phosphatase, and Urinalysis; CHEMOTHERAPY ROOM
APPOINTMENT: DACTINOmycin, vinCRIStine, and cyclophosphamide for 200 minutes.
Lab Only - Day 8, Cycle 1 – Planned for 6/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's sarcoma, Primitive neuroectodermal tumor of bone, Peripheral sarcoma of bone (Advanced); THERAPY:
DACTINOmycin 1.25 mg/m2 IV Day 1 (max dose = 2.5 mg), vinCRIStine 2 mg/m2 (max dose = 2 mg) IV Day 1, cyclophosphamide
1200 mg/m2 IV Day 1, mesna 400 mg/m2 IV prior to cyclophosphamide and 400 mg/m2 by mouth at 4 hours and 8 hours after start
of cyclophosphamide Day 1; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 cycles.
IV Access
Insert and Maintain Peripheral IV
Ordered dose of 2 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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Zztestonc,Jeff J [2507481]
6/13/2017 10:08:55 AM Page 3 of 18
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+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 1 – Planned for 6/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's sarcoma, Primitive neuroectodermal tumor of bone, Peripheral sarcoma of bone (Advanced); THERAPY:
DACTINOmycin 1.25 mg/m2 IV Day 1 (max dose = 2.5 mg), vinCRIStine 2 mg/m2 (max dose = 2 mg) IV Day 1, cyclophosphamide
1200 mg/m2 IV Day 1, mesna 400 mg/m2 IV prior to cyclophosphamide and 400 mg/m2 by mouth at 4 hours and 8 hours after start
of cyclophosphamide Day 1; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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: Ewing's sarcoma, Primitive neuroectodermal tumor of bone, Peripheral sarcoma of bone (Advanced); THERAPY:
DACTINOmycin 1.25 mg/m2 IV Day 1 (max dose = 2.5 mg), vinCRIStine 2 mg/m2 (max dose = 2 mg) IV Day 1, cyclophosphamide
1200 mg/m2 IV Day 1, mesna 400 mg/m2 IV prior to cyclophosphamide and 400 mg/m2 by mouth at 4 hours and 8 hours after start
of cyclophosphamide Day 1; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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
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Zztestonc,Jeff J [2507481]
6/13/2017 10:08:55 AM Page 4 of 18
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+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
URINALYSIS WITH MICROSCOPY
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: CBC, ANC, Urine Heme.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1500/µL or Platelets less than or equal to 100K/µL or Urine
Hemoglobin greater than Trace.
Nursing Procedure, Assessment and Monitoring
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
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 10:08:55 AM Page 5 of 18
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
Treatment Medications
DACTINOmycin (COSMOGEN) injection 2,450 mcg
2,450 mcg (1.25 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
IV push over 1-5 minutes into running IV. Max dose = 2.5 mg
vinCRIStine (ONCOVIN) 3.9 mg in sodium chloride 0.9 % 25 mL bag
3.9 mg (rounded from 3.92 mg = 2 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) 784 mg in sodium chloride 0.9 % 50 mL bag
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give just prior to cyclophosphamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of
cyclophosphamide.
cyclophosphamide (CYTOXAN) 2,352 mg in sodium chloride 0.9 % 250 mL bag
2,352 mg (1,200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally)
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, Alkaline Phosphatase, and Urinalysis; CHEMOTHERAPY ROOM
APPOINTMENT: DACTINOmycin, vinCRIStine, and cyclophosphamide for 200 minutes.
Lab Only - Day 8, Cycle 2 – Planned for 7/11/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's sarcoma, Primitive neuroectodermal tumor of bone, Peripheral sarcoma of bone (Advanced); THERAPY:
DACTINOmycin 1.25 mg/m2 IV Day 1 (max dose = 2.5 mg), vinCRIStine 2 mg/m2 (max dose = 2 mg) IV Day 1, cyclophosphamide
1200 mg/m2 IV Day 1, mesna 400 mg/m2 IV prior to cyclophosphamide and 400 mg/m2 by mouth at 4 hours and 8 hours after start
of cyclophosphamide Day 1; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Ordered dose of 2 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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Zztestonc,Jeff J [2507481]
6/13/2017 10:08:55 AM Page 6 of 18
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Lab Only - Day 15, Cycle 2 – Planned for 7/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's sarcoma, Primitive neuroectodermal tumor of bone, Peripheral sarcoma of bone (Advanced); THERAPY:
DACTINOmycin 1.25 mg/m2 IV Day 1 (max dose = 2.5 mg), vinCRIStine 2 mg/m2 (max dose = 2 mg) IV Day 1, cyclophosphamide
1200 mg/m2 IV Day 1, mesna 400 mg/m2 IV prior to cyclophosphamide and 400 mg/m2 by mouth at 4 hours and 8 hours after start
of cyclophosphamide Day 1; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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: Ewing's sarcoma, Primitive neuroectodermal tumor of bone, Peripheral sarcoma of bone (Advanced); THERAPY:
DACTINOmycin 1.25 mg/m2 IV Day 1 (max dose = 2.5 mg), vinCRIStine 2 mg/m2 (max dose = 2 mg) IV Day 1, cyclophosphamide
1200 mg/m2 IV Day 1, mesna 400 mg/m2 IV prior to cyclophosphamide and 400 mg/m2 by mouth at 4 hours and 8 hours after start
of cyclophosphamide Day 1; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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
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Zztestonc,Jeff J [2507481]
6/13/2017 10:08:55 AM Page 7 of 18
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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
URINALYSIS WITH MICROSCOPY
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: CBC, ANC, Urine Heme.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1500/µL or Platelets less than or equal to 100K/µL or Urine
Hemoglobin greater than Trace.
Nursing Procedure, Assessment and Monitoring
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
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
Treatment Medications
DACTINOmycin (COSMOGEN) injection 2,450 mcg
2,450 mcg (1.25 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
IV push over 1-5 minutes into running IV. Max dose = 2.5 mg
vinCRIStine (ONCOVIN) 3.9 mg in sodium chloride 0.9 % 25 mL bag
3.9 mg (rounded from 3.92 mg = 2 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.
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Zztestonc,Jeff J [2507481]
6/13/2017 10:08:55 AM Page 8 of 18
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

mesna (MESNEX) 784 mg in sodium chloride 0.9 % 50 mL bag
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give just prior to cyclophosphamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of
cyclophosphamide.
cyclophosphamide (CYTOXAN) 2,352 mg in sodium chloride 0.9 % 250 mL bag
2,352 mg (1,200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally)
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, Alkaline Phosphatase, and Urinalysis; CHEMOTHERAPY ROOM
APPOINTMENT: DACTINOmycin, vinCRIStine, and cyclophosphamide for 200 minutes.
Lab Only - Day 8, Cycle 3 – Planned for 8/1/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's sarcoma, Primitive neuroectodermal tumor of bone, Peripheral sarcoma of bone (Advanced); THERAPY:
DACTINOmycin 1.25 mg/m2 IV Day 1 (max dose = 2.5 mg), vinCRIStine 2 mg/m2 (max dose = 2 mg) IV Day 1, cyclophosphamide
1200 mg/m2 IV Day 1, mesna 400 mg/m2 IV prior to cyclophosphamide and 400 mg/m2 by mouth at 4 hours and 8 hours after start
of cyclophosphamide Day 1; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 3 – Planned for 8/8/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's sarcoma, Primitive neuroectodermal tumor of bone, Peripheral sarcoma of bone (Advanced); THERAPY:
DACTINOmycin 1.25 mg/m2 IV Day 1 (max dose = 2.5 mg), vinCRIStine 2 mg/m2 (max dose = 2 mg) IV Day 1, cyclophosphamide
1200 mg/m2 IV Day 1, mesna 400 mg/m2 IV prior to cyclophosphamide and 400 mg/m2 by mouth at 4 hours and 8 hours after start
of cyclophosphamide Day 1; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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 2 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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Zztestonc,Jeff J [2507481]
6/13/2017 10:08:55 AM Page 9 of 18
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
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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: Ewing's sarcoma, Primitive neuroectodermal tumor of bone, Peripheral sarcoma of bone (Advanced); THERAPY:
DACTINOmycin 1.25 mg/m2 IV Day 1 (max dose = 2.5 mg), vinCRIStine 2 mg/m2 (max dose = 2 mg) IV Day 1, cyclophosphamide
1200 mg/m2 IV Day 1, mesna 400 mg/m2 IV prior to cyclophosphamide and 400 mg/m2 by mouth at 4 hours and 8 hours after start
of cyclophosphamide Day 1; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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
URINALYSIS WITH MICROSCOPY
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
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Zztestonc,Jeff J [2507481]
6/13/2017 10:08:55 AM Page 10 of 18
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 and resulted: CBC, ANC, Urine Heme.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1500/µL or Platelets less than or equal to 100K/µL or Urine
Hemoglobin greater than Trace.
Nursing Procedure, Assessment and Monitoring
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
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
Treatment Medications
DACTINOmycin (COSMOGEN) injection 2,450 mcg
2,450 mcg (1.25 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
IV push over 1-5 minutes into running IV. Max dose = 2.5 mg
vinCRIStine (ONCOVIN) 3.9 mg in sodium chloride 0.9 % 25 mL bag
3.9 mg (rounded from 3.92 mg = 2 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) 784 mg in sodium chloride 0.9 % 50 mL bag
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give just prior to cyclophosphamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of
cyclophosphamide.
cyclophosphamide (CYTOXAN) 2,352 mg in sodium chloride 0.9 % 250 mL bag
2,352 mg (1,200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally)
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally)
Ordered dose of 2 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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Zztestonc,Jeff J [2507481]
6/13/2017 10:08:55 AM Page 11 of 18
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, Alkaline Phosphatase, and Urinalysis; CHEMOTHERAPY ROOM
APPOINTMENT: DACTINOmycin, vinCRIStine, and cyclophosphamide for 200 minutes.
Lab Only - Day 8, Cycle 4 – Planned for 8/22/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's sarcoma, Primitive neuroectodermal tumor of bone, Peripheral sarcoma of bone (Advanced); THERAPY:
DACTINOmycin 1.25 mg/m2 IV Day 1 (max dose = 2.5 mg), vinCRIStine 2 mg/m2 (max dose = 2 mg) IV Day 1, cyclophosphamide
1200 mg/m2 IV Day 1, mesna 400 mg/m2 IV prior to cyclophosphamide and 400 mg/m2 by mouth at 4 hours and 8 hours after start
of cyclophosphamide Day 1; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 4 – Planned for 8/29/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's sarcoma, Primitive neuroectodermal tumor of bone, Peripheral sarcoma of bone (Advanced); THERAPY:
DACTINOmycin 1.25 mg/m2 IV Day 1 (max dose = 2.5 mg), vinCRIStine 2 mg/m2 (max dose = 2 mg) IV Day 1, cyclophosphamide
1200 mg/m2 IV Day 1, mesna 400 mg/m2 IV prior to cyclophosphamide and 400 mg/m2 by mouth at 4 hours and 8 hours after start
of cyclophosphamide Day 1; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 – 9/5/2017 through 9/25/2017 (21 days), Planned
Day 1, Cycle 5 – Planned for 9/5/2017
Treatment Plan Information
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Zztestonc,Jeff J [2507481]
6/13/2017 10:08:55 AM Page 12 of 18
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Ewing's sarcoma, Primitive neuroectodermal tumor of bone, Peripheral sarcoma of bone (Advanced); THERAPY:
DACTINOmycin 1.25 mg/m2 IV Day 1 (max dose = 2.5 mg), vinCRIStine 2 mg/m2 (max dose = 2 mg) IV Day 1, cyclophosphamide
1200 mg/m2 IV Day 1, mesna 400 mg/m2 IV prior to cyclophosphamide and 400 mg/m2 by mouth at 4 hours and 8 hours after start
of cyclophosphamide Day 1; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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
URINALYSIS WITH MICROSCOPY
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: CBC, ANC, Urine Heme.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1500/µL or Platelets less than or equal to 100K/µL or Urine
Hemoglobin greater than Trace.
Nursing Procedure, Assessment and Monitoring
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
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 10:08:55 AM Page 13 of 18
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
Treatment Medications
DACTINOmycin (COSMOGEN) injection 2,450 mcg
2,450 mcg (1.25 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
IV push over 1-5 minutes into running IV. Max dose = 2.5 mg
vinCRIStine (ONCOVIN) 3.9 mg in sodium chloride 0.9 % 25 mL bag
3.9 mg (rounded from 3.92 mg = 2 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) 784 mg in sodium chloride 0.9 % 50 mL bag
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give just prior to cyclophosphamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of
cyclophosphamide.
cyclophosphamide (CYTOXAN) 2,352 mg in sodium chloride 0.9 % 250 mL bag
2,352 mg (1,200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally)
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, Alkaline Phosphatase, and Urinalysis; CHEMOTHERAPY ROOM
APPOINTMENT: DACTINOmycin, vinCRIStine, and cyclophosphamide for 200 minutes.
Lab Only - Day 8, Cycle 5 – Planned for 9/12/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's sarcoma, Primitive neuroectodermal tumor of bone, Peripheral sarcoma of bone (Advanced); THERAPY:
DACTINOmycin 1.25 mg/m2 IV Day 1 (max dose = 2.5 mg), vinCRIStine 2 mg/m2 (max dose = 2 mg) IV Day 1, cyclophosphamide
1200 mg/m2 IV Day 1, mesna 400 mg/m2 IV prior to cyclophosphamide and 400 mg/m2 by mouth at 4 hours and 8 hours after start
of cyclophosphamide Day 1; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 cycles.
Ordered dose of 2 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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Zztestonc,Jeff J [2507481]
6/13/2017 10:08:55 AM Page 14 of 18
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 5 – Planned for 9/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's sarcoma, Primitive neuroectodermal tumor of bone, Peripheral sarcoma of bone (Advanced); THERAPY:
DACTINOmycin 1.25 mg/m2 IV Day 1 (max dose = 2.5 mg), vinCRIStine 2 mg/m2 (max dose = 2 mg) IV Day 1, cyclophosphamide
1200 mg/m2 IV Day 1, mesna 400 mg/m2 IV prior to cyclophosphamide and 400 mg/m2 by mouth at 4 hours and 8 hours after start
of cyclophosphamide Day 1; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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: Ewing's sarcoma, Primitive neuroectodermal tumor of bone, Peripheral sarcoma of bone (Advanced); THERAPY:
DACTINOmycin 1.25 mg/m2 IV Day 1 (max dose = 2.5 mg), vinCRIStine 2 mg/m2 (max dose = 2 mg) IV Day 1, cyclophosphamide
1200 mg/m2 IV Day 1, mesna 400 mg/m2 IV prior to cyclophosphamide and 400 mg/m2 by mouth at 4 hours and 8 hours after start
of cyclophosphamide Day 1; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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 10:08:55 AM Page 15 of 18
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
URINALYSIS WITH MICROSCOPY
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: CBC, ANC, Urine Heme.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1500/µL or Platelets less than or equal to 100K/µL or Urine
Hemoglobin greater than Trace.
Nursing Procedure, Assessment and Monitoring
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
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Zztestonc,Jeff J [2507481]
6/13/2017 10:08:55 AM Page 16 of 18
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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
Treatment Medications
DACTINOmycin (COSMOGEN) injection 2,450 mcg
2,450 mcg (1.25 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
IV push over 1-5 minutes into running IV. Max dose = 2.5 mg
vinCRIStine (ONCOVIN) 3.9 mg in sodium chloride 0.9 % 25 mL bag
3.9 mg (rounded from 3.92 mg = 2 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) 784 mg in sodium chloride 0.9 % 50 mL bag
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give just prior to cyclophosphamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of
cyclophosphamide.
cyclophosphamide (CYTOXAN) 2,352 mg in sodium chloride 0.9 % 250 mL bag
2,352 mg (1,200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally)
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, Alkaline Phosphatase, and Urinalysis; CHEMOTHERAPY ROOM
APPOINTMENT: DACTINOmycin, vinCRIStine, and cyclophosphamide for 200 minutes.
Lab Only - Day 8, Cycle 6 – Planned for 10/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's sarcoma, Primitive neuroectodermal tumor of bone, Peripheral sarcoma of bone (Advanced); THERAPY:
DACTINOmycin 1.25 mg/m2 IV Day 1 (max dose = 2.5 mg), vinCRIStine 2 mg/m2 (max dose = 2 mg) IV Day 1, cyclophosphamide
1200 mg/m2 IV Day 1, mesna 400 mg/m2 IV prior to cyclophosphamide and 400 mg/m2 by mouth at 4 hours and 8 hours after start
of cyclophosphamide Day 1; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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
Follow-Up
Ordered dose of 2 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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Zztestonc,Jeff J [2507481]
6/13/2017 10:08:55 AM Page 17 of 18
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 6 – Planned for 10/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's sarcoma, Primitive neuroectodermal tumor of bone, Peripheral sarcoma of bone (Advanced); THERAPY:
DACTINOmycin 1.25 mg/m2 IV Day 1 (max dose = 2.5 mg), vinCRIStine 2 mg/m2 (max dose = 2 mg) IV Day 1, cyclophosphamide
1200 mg/m2 IV Day 1, mesna 400 mg/m2 IV prior to cyclophosphamide and 400 mg/m2 by mouth at 4 hours and 8 hours after start
of cyclophosphamide Day 1; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,Jeff J [2507481]
6/13/2017 10:08:55 AM Page 18 of 18
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org