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CSC Sarcoma Doxorubicin(21D:1,2) Ifosfamide(21D:1,2) VER 5-1-17 (HL 3469)

CSC Sarcoma Doxorubicin(21D:1,2) Ifosfamide(21D:1,2) VER 5-1-17 (HL 3469) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Sarcoma


CSC SARCOMA DOXORUBICIN(21D1,2)IFOSFAMIDE(21D1,2) VER 5-1-17 (HL 3469) – 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: Soft Tissue Sarcoma (Adjuvant/Advanced); THERAPY: doxorubicin 30 mg/m2 IV Day 1 and 2, mesna 1250 mg/m2 IV
prior to ifosfamide and mesna 1250 mg/m2 by mouth 4 and 8 hours after start of ifosfamide on Day 1 and 2, ifosfamide 3750 mg/m2
IV Day 1 and 2; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 cycles or until disease progression.
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+397, 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
MAGNESIUM
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 once. Take on Day 3., 80 mg, Disp-1 cap, R-5, ONCE starting S until S
dexamethasone (DECADRON) 4 MG tab
Take 2 tabs by mouth one time daily. Take on Day 3 and 4., 8 mg, Disp-24 tab, R-0, 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
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 10:15:11 AM Page 1 of 26
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)
SOFT TISSUE SARCOMA: Pervaiz N, et al. Cancer 2008;113(3): 573-81.
Reference Information (2)
SOFT TISSUE SARCOMA: Blum RH, et al. Cancer Chemother. Pharmacol 1993; 31(Suppl 2):S238-40.
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Adjuvant/Advanced); THERAPY: doxorubicin 30 mg/m2 IV Day 1 and 2, mesna 1250 mg/m2 IV
prior to ifosfamide and mesna 1250 mg/m2 by mouth 4 and 8 hours after start of ifosfamide on Day 1 and 2, ifosfamide 3750 mg/m2
IV Day 1 and 2; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 cycles or until disease progression.
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 Ejection Fraction
Confirm MUGA scan or ECHO-left ejection fraction reviewed by MD prior to Cycle 1 (required at baseline). Document confirmation of
review in progress note.
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, 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
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Zztestonc,Jeff J [2507481]
6/13/2017 10:15:11 AM Page 2 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9% BOLUS
1,000 mL, Intravenous, ONCE, 1 dose Starting when released
Give bolus 1 hour prior to chemotherapy.
sodium chloride 0.9 % infusion 1,000 mL
at 200 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000ml 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
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 59 mg
59 mg (rounded from 58.8 mg = 30 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
mesna (MESNEX) 2,450 mg in sodium chloride 0.9 % 50 mL bag
2,450 mg (1,250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse prior to ifosfamide infusion.
ifosfamide (IFEX) 7,350 mg in sodium chloride 0.9 % 500 mL bag
7,350 mg (3,750 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Take Home Medications
mesna (MESNEX) 400 MG tab
Take 6 tabs by mouth 2 times daily. Take 4 & 8 hours after start of ifosfamide on Day 1 & 2, 2,400 mg (rounded from 2,450 mg =
1,250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
MD may delete this order and order IV mesna.
Follow-Up
DAY 2 FOLLOW-UP
LABS: Urinalysis; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, ifosfamide, and mesna for 200 minutes.
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, ALT, Magnesium, Urinalysis; CHEMOTHERAPY ROOM
APPOINTMENT: doxorubicin, ifosfamide, and mesna for 200 minutes.
Day 2, Cycle 1 – Planned for 6/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Adjuvant/Advanced); THERAPY: doxorubicin 30 mg/m2 IV Day 1 and 2, mesna 1250 mg/m2 IV
prior to ifosfamide and mesna 1250 mg/m2 by mouth 4 and 8 hours after start of ifosfamide on Day 1 and 2, ifosfamide 3750 mg/m2
IV Day 1 and 2; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 cycles or until disease progression.
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Jeff J [2507481]
6/13/2017 10:15:11 AM Page 3 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
URINALYSIS WITH MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: Urine Heme.
Treatment Parameters
Hold treatment and notify authorizing prescriber for 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% BOLUS
1,000 mL, Intravenous, ONCE, 1 dose Starting when released
Give bolus 1 hour prior to chemotherapy.
sodium chloride 0.9 % infusion 1,000 mL
at 200 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000ml throughout treatment
Pre-Medications
aprepitant (EMEND) cap 80 mg
80 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
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 59 mg
59 mg (rounded from 58.8 mg = 30 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
mesna (MESNEX) 2,450 mg in sodium chloride 0.9 % 50 mL bag
2,450 mg (1,250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse prior to ifosfamide infusion.
ifosfamide (IFEX) 7,350 mg in sodium chloride 0.9 % 500 mL bag
7,350 mg (3,750 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
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Zztestonc,Jeff J [2507481]
6/13/2017 10:15:11 AM Page 4 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 8, Cycle 1 – Planned for 6/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Adjuvant/Advanced); THERAPY: doxorubicin 30 mg/m2 IV Day 1 and 2, mesna 1250 mg/m2 IV
prior to ifosfamide and mesna 1250 mg/m2 by mouth 4 and 8 hours after start of ifosfamide on Day 1 and 2, ifosfamide 3750 mg/m2
IV Day 1 and 2; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 cycles or until disease progression.
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+6 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+6 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: Soft Tissue Sarcoma (Adjuvant/Advanced); THERAPY: doxorubicin 30 mg/m2 IV Day 1 and 2, mesna 1250 mg/m2 IV
prior to ifosfamide and mesna 1250 mg/m2 by mouth 4 and 8 hours after start of ifosfamide on Day 1 and 2, ifosfamide 3750 mg/m2
IV Day 1 and 2; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 cycles or until disease progression.
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+13 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+13 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
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Zztestonc,Jeff J [2507481]
6/13/2017 10:15:11 AM Page 5 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

DISEASE: Soft Tissue Sarcoma (Adjuvant/Advanced); THERAPY: doxorubicin 30 mg/m2 IV Day 1 and 2, mesna
1250 mg/m2 IV prior to ifosfamide and mesna 1250 mg/m2 by mouth 4 and 8 hours after start of ifosfamide on Day
1 and 2, ifosfamide 3750 mg/m2 IV Day 1 and 2; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days;
COURSE: 6 cycles or until disease progression.
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+20 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+20 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+20 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+20 Approximate, Expires-S+365, Routine
BUN
Expected-S+20 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+20 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+20 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+20 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+20 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+20 Approximate, Expires-S+365, Routine
URINALYSIS WITH MICROSCOPY
Expected-S+20 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, 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 10:15:11 AM Page 6 of 26
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% BOLUS
1,000 mL, Intravenous, ONCE, 1 dose Starting when released
Give bolus 1 hour prior to chemotherapy.
sodium chloride 0.9 % infusion 1,000 mL
at 200 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000ml 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
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 59 mg
59 mg (rounded from 58.8 mg = 30 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
mesna (MESNEX) 2,450 mg in sodium chloride 0.9 % 50 mL bag
2,450 mg (1,250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse prior to ifosfamide infusion.
ifosfamide (IFEX) 7,350 mg in sodium chloride 0.9 % 500 mL bag
7,350 mg (3,750 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Take Home Medications
mesna (MESNEX) 400 MG tab
Take 6 tabs by mouth 2 times daily. Take 4 & 8 hours after start of ifosfamide on Day 1 & 2, 2,400 mg (rounded from 2,450 mg =
1,250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
MD may delete this order and order IV mesna.
Follow-Up
DAY 2 FOLLOW-UP
LABS: Urinalysis; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, ifosfamide, and mesna for 200 minutes.
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, ALT, Magnesium, Urinalysis; CHEMOTHERAPY ROOM
APPOINTMENT: doxorubicin, ifosfamide, and mesna for 200 minutes.
Day 2, Cycle 2 – Planned for 7/5/2017
Treatment Plan Information
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Zztestonc,Jeff J [2507481]
6/13/2017 10:15:11 AM Page 7 of 26
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: Soft Tissue Sarcoma (Adjuvant/Advanced); THERAPY: doxorubicin 30 mg/m2 IV Day 1 and 2, mesna
1250 mg/m2 IV prior to ifosfamide and mesna 1250 mg/m2 by mouth 4 and 8 hours after start of ifosfamide on Day
1 and 2, ifosfamide 3750 mg/m2 IV Day 1 and 2; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days;
COURSE: 6 cycles or until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
URINALYSIS WITH MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: Urine Heme.
Treatment Parameters
Hold treatment and notify authorizing prescriber for 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% BOLUS
1,000 mL, Intravenous, ONCE, 1 dose Starting when released
Give bolus 1 hour prior to chemotherapy.
sodium chloride 0.9 % infusion 1,000 mL
at 200 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000ml throughout treatment
Pre-Medications
aprepitant (EMEND) cap 80 mg
80 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
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 59 mg
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Zztestonc,Jeff J [2507481]
6/13/2017 10:15:11 AM Page 8 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

59 mg (rounded from 58.8 mg = 30 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
mesna (MESNEX) 2,450 mg in sodium chloride 0.9 % 50 mL bag
2,450 mg (1,250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse prior to ifosfamide infusion.
ifosfamide (IFEX) 7,350 mg in sodium chloride 0.9 % 500 mL bag
7,350 mg (3,750 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 8, Cycle 2 – Planned for 7/11/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Adjuvant/Advanced); THERAPY: doxorubicin 30 mg/m2 IV Day 1 and 2, mesna 1250 mg/m2 IV
prior to ifosfamide and mesna 1250 mg/m2 by mouth 4 and 8 hours after start of ifosfamide on Day 1 and 2, ifosfamide 3750 mg/m2
IV Day 1 and 2; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 cycles or until disease progression.
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+6 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+6 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 2 – Planned for 7/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Adjuvant/Advanced); THERAPY: doxorubicin 30 mg/m2 IV Day 1 and 2, mesna 1250 mg/m2 IV
prior to ifosfamide and mesna 1250 mg/m2 by mouth 4 and 8 hours after start of ifosfamide on Day 1 and 2, ifosfamide 3750 mg/m2
IV Day 1 and 2; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 cycles or until disease progression.
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+13 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+13 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
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Zztestonc,Jeff J [2507481]
6/13/2017 10:15:11 AM Page 9 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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: Soft Tissue Sarcoma (Adjuvant/Advanced); THERAPY: doxorubicin 30 mg/m2 IV Day 1 and 2, mesna 1250 mg/m2 IV
prior to ifosfamide and mesna 1250 mg/m2 by mouth 4 and 8 hours after start of ifosfamide on Day 1 and 2, ifosfamide 3750 mg/m2
IV Day 1 and 2; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 cycles or until disease progression.
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+20 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+20 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+20 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+20 Approximate, Expires-S+365, Routine
BUN
Expected-S+20 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+20 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+20 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+20 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+20 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+20 Approximate, Expires-S+365, Routine
URINALYSIS WITH MICROSCOPY
Expected-S+20 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, 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
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Zztestonc,Jeff J [2507481]
6/13/2017 10:15:11 AM Page 10 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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% BOLUS
1,000 mL, Intravenous, ONCE, 1 dose Starting when released
Give bolus 1 hour prior to chemotherapy.
sodium chloride 0.9 % infusion 1,000 mL
at 200 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000ml 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
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 59 mg
59 mg (rounded from 58.8 mg = 30 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
mesna (MESNEX) 2,450 mg in sodium chloride 0.9 % 50 mL bag
2,450 mg (1,250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse prior to ifosfamide infusion.
ifosfamide (IFEX) 7,350 mg in sodium chloride 0.9 % 500 mL bag
7,350 mg (3,750 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Take Home Medications
mesna (MESNEX) 400 MG tab
Take 6 tabs by mouth 2 times daily. Take 4 & 8 hours after start of ifosfamide on Day 1 & 2, 2,400 mg (rounded from 2,450 mg =
1,250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
MD may delete this order and order IV mesna.
Follow-Up
DAY 2 FOLLOW-UP
LABS: Urinalysis; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, ifosfamide, and mesna for 200 minutes.
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
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Zztestonc,Jeff J [2507481]
6/13/2017 10:15:11 AM Page 11 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done
locally), Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Magnesium, Urinalysis;
CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, ifosfamide, and mesna for 200 minutes.
Day 2, Cycle 3 – Planned for 7/26/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Adjuvant/Advanced); THERAPY: doxorubicin 30 mg/m2 IV Day 1 and 2, mesna 1250 mg/m2 IV
prior to ifosfamide and mesna 1250 mg/m2 by mouth 4 and 8 hours after start of ifosfamide on Day 1 and 2, ifosfamide 3750 mg/m2
IV Day 1 and 2; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 cycles or until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
URINALYSIS WITH MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: Urine Heme.
Treatment Parameters
Hold treatment and notify authorizing prescriber for 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% BOLUS
1,000 mL, Intravenous, ONCE, 1 dose Starting when released
Give bolus 1 hour prior to chemotherapy.
sodium chloride 0.9 % infusion 1,000 mL
at 200 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000ml throughout treatment
Pre-Medications
aprepitant (EMEND) cap 80 mg
80 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
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Zztestonc,Jeff J [2507481]
6/13/2017 10:15:11 AM Page 12 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

12 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 59 mg
59 mg (rounded from 58.8 mg = 30 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
mesna (MESNEX) 2,450 mg in sodium chloride 0.9 % 50 mL bag
2,450 mg (1,250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse prior to ifosfamide infusion.
ifosfamide (IFEX) 7,350 mg in sodium chloride 0.9 % 500 mL bag
7,350 mg (3,750 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 8, Cycle 3 – Planned for 8/1/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Adjuvant/Advanced); THERAPY: doxorubicin 30 mg/m2 IV Day 1 and 2, mesna 1250 mg/m2 IV
prior to ifosfamide and mesna 1250 mg/m2 by mouth 4 and 8 hours after start of ifosfamide on Day 1 and 2, ifosfamide 3750 mg/m2
IV Day 1 and 2; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 cycles or until disease progression.
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+6 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+6 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: Soft Tissue Sarcoma (Adjuvant/Advanced); THERAPY: doxorubicin 30 mg/m2 IV Day 1 and 2, mesna 1250 mg/m2 IV
prior to ifosfamide and mesna 1250 mg/m2 by mouth 4 and 8 hours after start of ifosfamide on Day 1 and 2, ifosfamide 3750 mg/m2
IV Day 1 and 2; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 cycles or until disease progression.
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+13 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
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Zztestonc,Jeff J [2507481]
6/13/2017 10:15:11 AM Page 13 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Expected-S+13 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: Soft Tissue Sarcoma (Adjuvant/Advanced); THERAPY: doxorubicin 30 mg/m2 IV Day 1 and 2, mesna 1250 mg/m2 IV
prior to ifosfamide and mesna 1250 mg/m2 by mouth 4 and 8 hours after start of ifosfamide on Day 1 and 2, ifosfamide 3750 mg/m2
IV Day 1 and 2; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 cycles or until disease progression.
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+20 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+20 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+20 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+20 Approximate, Expires-S+365, Routine
BUN
Expected-S+20 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+20 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+20 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+20 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+20 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+20 Approximate, Expires-S+365, Routine
URINALYSIS WITH MICROSCOPY
Expected-S+20 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, Urine Heme.
Treatment Parameters
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Zztestonc,Jeff J [2507481]
6/13/2017 10:15:11 AM Page 14 of 26
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 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% BOLUS
1,000 mL, Intravenous, ONCE, 1 dose Starting when released
Give bolus 1 hour prior to chemotherapy.
sodium chloride 0.9 % infusion 1,000 mL
at 200 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000ml 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
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 59 mg
59 mg (rounded from 58.8 mg = 30 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
mesna (MESNEX) 2,450 mg in sodium chloride 0.9 % 50 mL bag
2,450 mg (1,250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse prior to ifosfamide infusion.
ifosfamide (IFEX) 7,350 mg in sodium chloride 0.9 % 500 mL bag
7,350 mg (3,750 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Take Home Medications
mesna (MESNEX) 400 MG tab
Take 6 tabs by mouth 2 times daily. Take 4 & 8 hours after start of ifosfamide on Day 1 & 2, 2,400 mg (rounded from 2,450 mg =
1,250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
MD may delete this order and order IV mesna.
Follow-Up
DAY 2 FOLLOW-UP
LABS: Urinalysis; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, ifosfamide, and mesna for 200 minutes.
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
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Zztestonc,Jeff J [2507481]
6/13/2017 10:15:11 AM Page 15 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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, ALT, Magnesium, Urinalysis; CHEMOTHERAPY ROOM
APPOINTMENT: doxorubicin, ifosfamide, and mesna for 200 minutes.
Day 2, Cycle 4 – Planned for 8/16/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Adjuvant/Advanced); THERAPY: doxorubicin 30 mg/m2 IV Day 1 and 2, mesna 1250 mg/m2 IV
prior to ifosfamide and mesna 1250 mg/m2 by mouth 4 and 8 hours after start of ifosfamide on Day 1 and 2, ifosfamide 3750 mg/m2
IV Day 1 and 2; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 cycles or until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
URINALYSIS WITH MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: Urine Heme.
Treatment Parameters
Hold treatment and notify authorizing prescriber for 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% BOLUS
1,000 mL, Intravenous, ONCE, 1 dose Starting when released
Give bolus 1 hour prior to chemotherapy.
sodium chloride 0.9 % infusion 1,000 mL
at 200 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000ml throughout treatment
Pre-Medications
aprepitant (EMEND) cap 80 mg
80 mg, Oral, ONCE, 1 dose Starting when released
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Zztestonc,Jeff J [2507481]
6/13/2017 10:15:11 AM Page 16 of 26
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
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 59 mg
59 mg (rounded from 58.8 mg = 30 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
mesna (MESNEX) 2,450 mg in sodium chloride 0.9 % 50 mL bag
2,450 mg (1,250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse prior to ifosfamide infusion.
ifosfamide (IFEX) 7,350 mg in sodium chloride 0.9 % 500 mL bag
7,350 mg (3,750 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 8, Cycle 4 – Planned for 8/22/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Adjuvant/Advanced); THERAPY: doxorubicin 30 mg/m2 IV Day 1 and 2, mesna 1250 mg/m2 IV
prior to ifosfamide and mesna 1250 mg/m2 by mouth 4 and 8 hours after start of ifosfamide on Day 1 and 2, ifosfamide 3750 mg/m2
IV Day 1 and 2; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 cycles or until disease progression.
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+6 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+6 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: Soft Tissue Sarcoma (Adjuvant/Advanced); THERAPY: doxorubicin 30 mg/m2 IV Day 1 and 2, mesna 1250 mg/m2 IV
prior to ifosfamide and mesna 1250 mg/m2 by mouth 4 and 8 hours after start of ifosfamide on Day 1 and 2, ifosfamide 3750 mg/m2
IV Day 1 and 2; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 cycles or until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
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Zztestonc,Jeff J [2507481]
6/13/2017 10:15:11 AM Page 17 of 26
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+13 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+13 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
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Adjuvant/Advanced); THERAPY: doxorubicin 30 mg/m2 IV Day 1 and 2, mesna 1250 mg/m2 IV
prior to ifosfamide and mesna 1250 mg/m2 by mouth 4 and 8 hours after start of ifosfamide on Day 1 and 2, ifosfamide 3750 mg/m2
IV Day 1 and 2; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 cycles or until disease progression.
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+20 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+20 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+20 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+20 Approximate, Expires-S+365, Routine
BUN
Expected-S+20 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+20 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+20 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+20 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+20 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+20 Approximate, Expires-S+365, Routine
URINALYSIS WITH MICROSCOPY
Expected-S+20 Approximate, Expires-S+365, Routine
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Zztestonc,Jeff J [2507481]
6/13/2017 10:15:11 AM Page 18 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, 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% BOLUS
1,000 mL, Intravenous, ONCE, 1 dose Starting when released
Give bolus 1 hour prior to chemotherapy.
sodium chloride 0.9 % infusion 1,000 mL
at 200 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000ml 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
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 59 mg
59 mg (rounded from 58.8 mg = 30 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
mesna (MESNEX) 2,450 mg in sodium chloride 0.9 % 50 mL bag
2,450 mg (1,250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse prior to ifosfamide infusion.
ifosfamide (IFEX) 7,350 mg in sodium chloride 0.9 % 500 mL bag
7,350 mg (3,750 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Take Home Medications
mesna (MESNEX) 400 MG tab
Take 6 tabs by mouth 2 times daily. Take 4 & 8 hours after start of ifosfamide on Day 1 & 2, 2,400 mg (rounded from 2,450 mg =
1,250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
MD may delete this order and order IV mesna.
Follow-Up
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Zztestonc,Jeff J [2507481]
6/13/2017 10:15:11 AM Page 19 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

DAY 2 FOLLOW-UP
LABS: Urinalysis; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, ifosfamide, and mesna for 200 minutes.
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, ALT, Magnesium, Urinalysis; CHEMOTHERAPY ROOM
APPOINTMENT: doxorubicin, ifosfamide, and mesna for 200 minutes.
Day 2, Cycle 5 – Planned for 9/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Adjuvant/Advanced); THERAPY: doxorubicin 30 mg/m2 IV Day 1 and 2, mesna 1250 mg/m2 IV
prior to ifosfamide and mesna 1250 mg/m2 by mouth 4 and 8 hours after start of ifosfamide on Day 1 and 2, ifosfamide 3750 mg/m2
IV Day 1 and 2; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 cycles or until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
URINALYSIS WITH MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: Urine Heme.
Treatment Parameters
Hold treatment and notify authorizing prescriber for 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% BOLUS
1,000 mL, Intravenous, ONCE, 1 dose Starting when released
Give bolus 1 hour prior to chemotherapy.
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Zztestonc,Jeff J [2507481]
6/13/2017 10:15:11 AM Page 20 of 26
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 1,000 mL
at 200 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000ml throughout treatment
Pre-Medications
aprepitant (EMEND) cap 80 mg
80 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
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 59 mg
59 mg (rounded from 58.8 mg = 30 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
mesna (MESNEX) 2,450 mg in sodium chloride 0.9 % 50 mL bag
2,450 mg (1,250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse prior to ifosfamide infusion.
ifosfamide (IFEX) 7,350 mg in sodium chloride 0.9 % 500 mL bag
7,350 mg (3,750 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 8, Cycle 5 – Planned for 9/12/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Adjuvant/Advanced); THERAPY: doxorubicin 30 mg/m2 IV Day 1 and 2, mesna 1250 mg/m2 IV
prior to ifosfamide and mesna 1250 mg/m2 by mouth 4 and 8 hours after start of ifosfamide on Day 1 and 2, ifosfamide 3750 mg/m2
IV Day 1 and 2; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 cycles or until disease progression.
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+6 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+6 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: Soft Tissue Sarcoma (Adjuvant/Advanced); THERAPY: doxorubicin 30 mg/m2 IV Day 1 and 2, mesna 1250 mg/m2 IV
prior to ifosfamide and mesna 1250 mg/m2 by mouth 4 and 8 hours after start of ifosfamide on Day 1 and 2, ifosfamide 3750 mg/m2
IV Day 1 and 2; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 cycles or until disease progression.
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Zztestonc,Jeff J [2507481]
6/13/2017 10:15:11 AM Page 21 of 26
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+13 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+13 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: Soft Tissue Sarcoma (Adjuvant/Advanced); THERAPY: doxorubicin 30 mg/m2 IV Day 1 and 2, mesna 1250 mg/m2 IV
prior to ifosfamide and mesna 1250 mg/m2 by mouth 4 and 8 hours after start of ifosfamide on Day 1 and 2, ifosfamide 3750 mg/m2
IV Day 1 and 2; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 cycles or until disease progression.
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+20 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+20 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+20 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+20 Approximate, Expires-S+365, Routine
BUN
Expected-S+20 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+20 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+20 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+20 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
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Zztestonc,Jeff J [2507481]
6/13/2017 10:15:11 AM Page 22 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Expected-S+20 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+20 Approximate, Expires-S+365, Routine
URINALYSIS WITH MICROSCOPY
Expected-S+20 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, 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% BOLUS
1,000 mL, Intravenous, ONCE, 1 dose Starting when released
Give bolus 1 hour prior to chemotherapy.
sodium chloride 0.9 % infusion 1,000 mL
at 200 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000ml 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
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 59 mg
59 mg (rounded from 58.8 mg = 30 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
mesna (MESNEX) 2,450 mg in sodium chloride 0.9 % 50 mL bag
2,450 mg (1,250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse prior to ifosfamide infusion.
ifosfamide (IFEX) 7,350 mg in sodium chloride 0.9 % 500 mL bag
7,350 mg (3,750 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
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Zztestonc,Jeff J [2507481]
6/13/2017 10:15:11 AM Page 23 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Take Home Medications
mesna (MESNEX) 400 MG tab
Take 6 tabs by mouth 2 times daily. Take 4 & 8 hours after start of ifosfamide on Day 1 & 2, 2,400 mg (rounded from 2,450 mg =
1,250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
MD may delete this order and order IV mesna.
Follow-Up
DAY 2 FOLLOW-UP
LABS: Urinalysis; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, ifosfamide, and mesna for 200 minutes.
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, ALT, Magnesium, Urinalysis; CHEMOTHERAPY ROOM
APPOINTMENT: doxorubicin, ifosfamide, and mesna for 200 minutes.
Day 2, Cycle 6 – Planned for 9/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Adjuvant/Advanced); THERAPY: doxorubicin 30 mg/m2 IV Day 1 and 2, mesna 1250 mg/m2 IV
prior to ifosfamide and mesna 1250 mg/m2 by mouth 4 and 8 hours after start of ifosfamide on Day 1 and 2, ifosfamide 3750 mg/m2
IV Day 1 and 2; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 cycles or until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
URINALYSIS WITH MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: Urine Heme.
Treatment Parameters
Hold treatment and notify authorizing prescriber for 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.
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Zztestonc,Jeff J [2507481]
6/13/2017 10:15:11 AM Page 24 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Hydration
sodium chloride 0.9% BOLUS
1,000 mL, Intravenous, ONCE, 1 dose Starting when released
Give bolus 1 hour prior to chemotherapy.
sodium chloride 0.9 % infusion 1,000 mL
at 200 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000ml throughout treatment
Pre-Medications
aprepitant (EMEND) cap 80 mg
80 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
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 59 mg
59 mg (rounded from 58.8 mg = 30 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
mesna (MESNEX) 2,450 mg in sodium chloride 0.9 % 50 mL bag
2,450 mg (1,250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse prior to ifosfamide infusion.
ifosfamide (IFEX) 7,350 mg in sodium chloride 0.9 % 500 mL bag
7,350 mg (3,750 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 8, Cycle 6 – Planned for 10/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Adjuvant/Advanced); THERAPY: doxorubicin 30 mg/m2 IV Day 1 and 2, mesna 1250 mg/m2 IV
prior to ifosfamide and mesna 1250 mg/m2 by mouth 4 and 8 hours after start of ifosfamide on Day 1 and 2, ifosfamide 3750 mg/m2
IV Day 1 and 2; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 cycles or until disease progression.
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+6 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+6 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 6 – Planned for 10/10/2017
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Zztestonc,Jeff J [2507481]
6/13/2017 10:15:11 AM Page 25 of 26
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: Soft Tissue Sarcoma (Adjuvant/Advanced); THERAPY: doxorubicin 30 mg/m2 IV Day 1 and 2, mesna 1250 mg/m2 IV
prior to ifosfamide and mesna 1250 mg/m2 by mouth 4 and 8 hours after start of ifosfamide on Day 1 and 2, ifosfamide 3750 mg/m2
IV Day 1 and 2; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 cycles or until disease progression.
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+13 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+13 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 10:15:11 AM Page 26 of 26
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org