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CSC Sarcoma Etoposide(21D:1,2,3) Ifosfamide(21D:1,2,3) VER 5-1-17 (HL 961)

CSC Sarcoma Etoposide(21D:1,2,3) Ifosfamide(21D:1,2,3) VER 5-1-17 (HL 961) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Sarcoma


CSC SARCOMA ETOPOSIDE(21D1,2,3)IFOSFAMIDE(21D1,2,3) VER 5-1-17 (HL 961) – 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 (Advanced); THERAPY: ifosfamide 1800 mg/m2 IV Day 1, 2, and 3, mesna 600 mg/m2 IV prior to
ifosfamide and 600 mg/m2 by mouth at 4 hours and 8 hours after start of ifosfamide Day 1, 2, and 3; etoposide 100 mg/m2 Day 1, 2,
and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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+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
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)
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.
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Zztestonc,Jeff J [2507481]
6/13/2017 12:08:40 PM Page 1 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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: Miser JS, et al. J Clin Oncol 1987;5:1191-8.
Reference Information (2)
SARCOMA: Kung FH, et al. Cancer 1993;71:1898-903.
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Advanced); THERAPY: ifosfamide 1800 mg/m2 IV Day 1, 2, and 3, mesna 600 mg/m2 IV prior to
ifosfamide and 600 mg/m2 by mouth at 4 hours and 8 hours after start of ifosfamide Day 1, 2, and 3; etoposide 100 mg/m2 Day 1, 2,
and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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 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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
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Zztestonc,Jeff J [2507481]
6/13/2017 12:08:40 PM Page 2 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

mesna (MESNEX) 1,176 mg in sodium chloride 0.9 % 50 mL bag
1,176 mg (600 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give prior to start of ifosfamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
ifosfamide (IFEX) 3,530 mg in sodium chloride 0.9 % 250 mL bag
3,530 mg (rounded from 3,528 mg = 1,800 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
etoposide (VEPESID) 196 mg in sodium chloride 0.9 % 500 mL NSS bag
196 mg (100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): oral mesna at 4 hours and 8 hours after the
start of ifosfamide (dispensed on Day 1 of each cycle).
Take Home Medications
mesna (MESNEX) 400 MG tab
Take 3 tabs by mouth 2 times daily. Take 4 & 8 hours after start of ifosfamide on Day 1, 2, and 3., 1,200 mg (rounded from 1,176
mg = 600 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S, Local Printer
MD may delete this order and order IV mesna.
Follow-Up
DAY 2 FOLLOW-UP
LABS: Urinalysis; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide, mesna, and etoposide for 200 minutes.
DAY 3 FOLLOW-UP
LABS: Urinalysis; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide, mesna, and etoposide 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 done locally), Electrolytes,
Glucose, BUN, Creatinine, Total Bilirubin, AST, Alkaline Phosphatase, and Urinalysis; CHEMOTHERAPY ROOM APPOINTMENT:
ifosfamide, mesna, and etoposide for 200 minutes.
Day 2, Cycle 1 – Planned for 6/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Advanced); THERAPY: ifosfamide 1800 mg/m2 IV Day 1, 2, and 3, mesna 600 mg/m2 IV prior to
ifosfamide and 600 mg/m2 by mouth at 4 hours and 8 hours after start of ifosfamide Day 1, 2, and 3; etoposide 100 mg/m2 Day 1, 2,
and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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.
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Zztestonc,Jeff J [2507481]
6/13/2017 12:08:40 PM Page 3 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
mesna (MESNEX) 1,176 mg in sodium chloride 0.9 % 50 mL bag
1,176 mg (600 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give prior to start of ifosfamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
ifosfamide (IFEX) 3,530 mg in sodium chloride 0.9 % 250 mL bag
3,530 mg (rounded from 3,528 mg = 1,800 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
etoposide (VEPESID) 196 mg in sodium chloride 0.9 % 500 mL NSS bag
196 mg (100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): oral mesna at 4 hours and 8 hours after the
start of ifosfamide (dispensed on Day 1 of each cycle).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 1 – Planned for 6/15/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Advanced); THERAPY: ifosfamide 1800 mg/m2 IV Day 1, 2, and 3, mesna 600 mg/m2 IV prior to
ifosfamide and 600 mg/m2 by mouth at 4 hours and 8 hours after start of ifosfamide Day 1, 2, and 3; etoposide 100 mg/m2 Day 1, 2,
and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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 12:08:40 PM Page 4 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
mesna (MESNEX) 1,176 mg in sodium chloride 0.9 % 50 mL bag
1,176 mg (600 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give prior to start of ifosfamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
ifosfamide (IFEX) 3,530 mg in sodium chloride 0.9 % 250 mL bag
3,530 mg (rounded from 3,528 mg = 1,800 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
etoposide (VEPESID) 196 mg in sodium chloride 0.9 % 500 mL NSS bag
196 mg (100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): oral mesna at 4 hours and 8 hours after the
start of ifosfamide (dispensed on Day 1 of each cycle).
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
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Zztestonc,Jeff J [2507481]
6/13/2017 12:08:40 PM Page 5 of 42
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 (Advanced); THERAPY: ifosfamide 1800 mg/m2 IV Day 1, 2, and 3, mesna 600 mg/m2 IV prior to
ifosfamide and 600 mg/m2 by mouth at 4 hours and 8 hours after start of ifosfamide Day 1, 2, and 3; etoposide 100 mg/m2 Day 1, 2,
and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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+5 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+5 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 (Advanced); THERAPY: ifosfamide 1800 mg/m2 IV Day 1, 2, and 3, mesna 600 mg/m2 IV prior to
ifosfamide and 600 mg/m2 by mouth at 4 hours and 8 hours after start of ifosfamide Day 1, 2, and 3; etoposide 100 mg/m2 Day 1, 2,
and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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+12 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+12 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: Soft Tissue Sarcoma (Advanced); THERAPY: ifosfamide 1800 mg/m2 IV Day 1, 2, and 3, mesna 600 mg/m2 IV prior to
ifosfamide and 600 mg/m2 by mouth at 4 hours and 8 hours after start of ifosfamide Day 1, 2, and 3; etoposide 100 mg/m2 Day 1, 2,
and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 cycles or until disease progression.
Consent
Verify Consent
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Zztestonc,Jeff J [2507481]
6/13/2017 12:08:40 PM Page 6 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+19 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+19 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+19 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+19 Approximate, Expires-S+365, Routine
BUN
Expected-S+19 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+19 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+19 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+19 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+19 Approximate, Expires-S+365, Routine
URINALYSIS WITH MICROSCOPY
Expected-S+19 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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
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Zztestonc,Jeff J [2507481]
6/13/2017 12:08:40 PM Page 7 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
mesna (MESNEX) 1,176 mg in sodium chloride 0.9 % 50 mL bag
1,176 mg (600 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give prior to start of ifosfamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
ifosfamide (IFEX) 3,530 mg in sodium chloride 0.9 % 250 mL bag
3,530 mg (rounded from 3,528 mg = 1,800 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
etoposide (VEPESID) 196 mg in sodium chloride 0.9 % 500 mL NSS bag
196 mg (100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): oral mesna at 4 hours and 8 hours after the
start of ifosfamide (dispensed on Day 1 of each cycle).
Take Home Medications
mesna (MESNEX) 400 MG tab
Take 3 tabs by mouth 2 times daily. Take 4 & 8 hours after start of ifosfamide on Day 1, 2, and 3., 1,200 mg (rounded from 1,176
mg = 600 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S, Local Printer
MD may delete this order and order IV mesna.
Follow-Up
DAY 2 FOLLOW-UP
LABS: Urinalysis; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide, mesna, and etoposide for 200 minutes.
DAY 3 FOLLOW-UP
LABS: Urinalysis; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide, mesna, and etoposide 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 done locally), Electrolytes,
Glucose, BUN, Creatinine, Total Bilirubin, AST, Alkaline Phosphatase, and Urinalysis; CHEMOTHERAPY ROOM APPOINTMENT:
ifosfamide, mesna, and etoposide for 200 minutes.
Day 2, Cycle 2 – Planned for 7/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Advanced); THERAPY: ifosfamide 1800 mg/m2 IV Day 1, 2, and 3, mesna 600 mg/m2 IV prior to
ifosfamide and 600 mg/m2 by mouth at 4 hours and 8 hours after start of ifosfamide Day 1, 2, and 3; etoposide 100 mg/m2 Day 1, 2,
and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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
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Zztestonc,Jeff J [2507481]
6/13/2017 12:08:40 PM Page 8 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

URINALYSIS WITH MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, 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
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.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Treatment Medications
mesna (MESNEX) 1,176 mg in sodium chloride 0.9 % 50 mL bag
1,176 mg (600 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give prior to start of ifosfamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
ifosfamide (IFEX) 3,530 mg in sodium chloride 0.9 % 250 mL bag
3,530 mg (rounded from 3,528 mg = 1,800 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
etoposide (VEPESID) 196 mg in sodium chloride 0.9 % 500 mL NSS bag
196 mg (100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): oral mesna at 4 hours and 8 hours after the
start of ifosfamide (dispensed on Day 1 of each cycle).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 2 – Planned for 7/6/2017
Treatment Plan Information
Treatment Plan Summary
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Zztestonc,Jeff J [2507481]
6/13/2017 12:08:40 PM Page 9 of 42
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 (Advanced); THERAPY: ifosfamide 1800 mg/m2 IV Day 1, 2, and 3, mesna 600 mg/m2 IV prior to
ifosfamide and 600 mg/m2 by mouth at 4 hours and 8 hours after start of ifosfamide Day 1, 2, and 3; etoposide 100 mg/m2 Day 1, 2,
and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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
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.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Treatment Medications
mesna (MESNEX) 1,176 mg in sodium chloride 0.9 % 50 mL bag
1,176 mg (600 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give prior to start of ifosfamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
ifosfamide (IFEX) 3,530 mg in sodium chloride 0.9 % 250 mL bag
3,530 mg (rounded from 3,528 mg = 1,800 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
etoposide (VEPESID) 196 mg in sodium chloride 0.9 % 500 mL NSS bag
196 mg (100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): oral mesna at 4 hours and 8 hours after the
start of ifosfamide (dispensed on Day 1 of each cycle).
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Zztestonc,Jeff J [2507481]
6/13/2017 12:08:40 PM Page 10 of 42
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 2 – Planned for 7/11/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Advanced); THERAPY: ifosfamide 1800 mg/m2 IV Day 1, 2, and 3, mesna 600 mg/m2 IV prior to
ifosfamide and 600 mg/m2 by mouth at 4 hours and 8 hours after start of ifosfamide Day 1, 2, and 3; etoposide 100 mg/m2 Day 1, 2,
and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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+5 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+5 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 (Advanced); THERAPY: ifosfamide 1800 mg/m2 IV Day 1, 2, and 3, mesna 600 mg/m2 IV prior to
ifosfamide and 600 mg/m2 by mouth at 4 hours and 8 hours after start of ifosfamide Day 1, 2, and 3; etoposide 100 mg/m2 Day 1, 2,
and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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+12 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+12 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
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Zztestonc,Jeff J [2507481]
6/13/2017 12:08:40 PM Page 11 of 42
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 (Advanced); THERAPY: ifosfamide 1800 mg/m2 IV Day 1, 2, and 3, mesna 600
mg/m2 IV prior to ifosfamide and 600 mg/m2 by mouth at 4 hours and 8 hours after start of ifosfamide Day 1, 2, and
3; etoposide 100 mg/m2 Day 1, 2, and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6
to 8 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+19 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+19 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+19 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+19 Approximate, Expires-S+365, Routine
BUN
Expected-S+19 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+19 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+19 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+19 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+19 Approximate, Expires-S+365, Routine
URINALYSIS WITH MICROSCOPY
Expected-S+19 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
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 12:08:40 PM Page 12 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
mesna (MESNEX) 1,176 mg in sodium chloride 0.9 % 50 mL bag
1,176 mg (600 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give prior to start of ifosfamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
ifosfamide (IFEX) 3,530 mg in sodium chloride 0.9 % 250 mL bag
3,530 mg (rounded from 3,528 mg = 1,800 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
etoposide (VEPESID) 196 mg in sodium chloride 0.9 % 500 mL NSS bag
196 mg (100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): oral mesna at 4 hours and 8 hours after the
start of ifosfamide (dispensed on Day 1 of each cycle).
Take Home Medications
mesna (MESNEX) 400 MG tab
Take 3 tabs by mouth 2 times daily. Take 4 & 8 hours after start of ifosfamide on Day 1, 2, and 3., 1,200 mg (rounded from 1,176
mg = 600 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S, Local Printer
MD may delete this order and order IV mesna.
Follow-Up
DAY 2 FOLLOW-UP
LABS: Urinalysis; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide, mesna, and etoposide for 200 minutes.
DAY 3 FOLLOW-UP
LABS: Urinalysis; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide, mesna, and etoposide 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 done locally), Electrolytes,
Glucose, BUN, Creatinine, Total Bilirubin, AST, Alkaline Phosphatase, and Urinalysis; CHEMOTHERAPY ROOM APPOINTMENT:
ifosfamide, mesna, and etoposide for 200 minutes.
Day 2, Cycle 3 – Planned for 7/26/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Advanced); THERAPY: ifosfamide 1800 mg/m2 IV Day 1, 2, and 3, mesna 600 mg/m2 IV prior to
ifosfamide and 600 mg/m2 by mouth at 4 hours and 8 hours after start of ifosfamide Day 1, 2, and 3; etoposide 100 mg/m2 Day 1, 2,
and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 cycles or until disease progression.
IV Access
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Zztestonc,Jeff J [2507481]
6/13/2017 12:08:40 PM Page 13 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
URINALYSIS WITH MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, 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
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.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Treatment Medications
mesna (MESNEX) 1,176 mg in sodium chloride 0.9 % 50 mL bag
1,176 mg (600 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give prior to start of ifosfamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
ifosfamide (IFEX) 3,530 mg in sodium chloride 0.9 % 250 mL bag
3,530 mg (rounded from 3,528 mg = 1,800 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
etoposide (VEPESID) 196 mg in sodium chloride 0.9 % 500 mL NSS bag
196 mg (100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): oral mesna at 4 hours and 8 hours after the
start of ifosfamide (dispensed on Day 1 of each cycle).
Follow-Up
VERIFY APPOINTMENTS
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Zztestonc,Jeff J [2507481]
6/13/2017 12:08:40 PM Page 14 of 42
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.
Day 3, Cycle 3 – Planned for 7/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Advanced); THERAPY: ifosfamide 1800 mg/m2 IV Day 1, 2, and 3, mesna 600 mg/m2 IV prior to
ifosfamide and 600 mg/m2 by mouth at 4 hours and 8 hours after start of ifosfamide Day 1, 2, and 3; etoposide 100 mg/m2 Day 1, 2,
and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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
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.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Treatment Medications
mesna (MESNEX) 1,176 mg in sodium chloride 0.9 % 50 mL bag
1,176 mg (600 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give prior to start of ifosfamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
ifosfamide (IFEX) 3,530 mg in sodium chloride 0.9 % 250 mL bag
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Zztestonc,Jeff J [2507481]
6/13/2017 12:08:40 PM Page 15 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

3,530 mg (rounded from 3,528 mg = 1,800 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
etoposide (VEPESID) 196 mg in sodium chloride 0.9 % 500 mL NSS bag
196 mg (100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): oral mesna at 4 hours and 8 hours after the
start of ifosfamide (dispensed on Day 1 of each cycle).
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 (Advanced); THERAPY: ifosfamide 1800 mg/m2 IV Day 1, 2, and 3, mesna 600 mg/m2 IV prior to
ifosfamide and 600 mg/m2 by mouth at 4 hours and 8 hours after start of ifosfamide Day 1, 2, and 3; etoposide 100 mg/m2 Day 1, 2,
and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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+5 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+5 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 (Advanced); THERAPY: ifosfamide 1800 mg/m2 IV Day 1, 2, and 3, mesna 600 mg/m2 IV prior to
ifosfamide and 600 mg/m2 by mouth at 4 hours and 8 hours after start of ifosfamide Day 1, 2, and 3; etoposide 100 mg/m2 Day 1, 2,
and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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+12 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+12 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
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Zztestonc,Jeff J [2507481]
6/13/2017 12:08:40 PM Page 16 of 42
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 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 (Advanced); THERAPY: ifosfamide 1800 mg/m2 IV Day 1, 2, and 3, mesna 600 mg/m2 IV prior to
ifosfamide and 600 mg/m2 by mouth at 4 hours and 8 hours after start of ifosfamide Day 1, 2, and 3; etoposide 100 mg/m2 Day 1, 2,
and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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+19 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+19 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+19 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+19 Approximate, Expires-S+365, Routine
BUN
Expected-S+19 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+19 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+19 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+19 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+19 Approximate, Expires-S+365, Routine
URINALYSIS WITH MICROSCOPY
Expected-S+19 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
Flush Venous Access Device per Guidelines
Order details
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Zztestonc,Jeff J [2507481]
6/13/2017 12:08:40 PM Page 17 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
mesna (MESNEX) 1,176 mg in sodium chloride 0.9 % 50 mL bag
1,176 mg (600 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give prior to start of ifosfamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
ifosfamide (IFEX) 3,530 mg in sodium chloride 0.9 % 250 mL bag
3,530 mg (rounded from 3,528 mg = 1,800 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
etoposide (VEPESID) 196 mg in sodium chloride 0.9 % 500 mL NSS bag
196 mg (100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): oral mesna at 4 hours and 8 hours after the
start of ifosfamide (dispensed on Day 1 of each cycle).
Take Home Medications
mesna (MESNEX) 400 MG tab
Take 3 tabs by mouth 2 times daily. Take 4 & 8 hours after start of ifosfamide on Day 1, 2, and 3., 1,200 mg (rounded from 1,176
mg = 600 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S, Local Printer
MD may delete this order and order IV mesna.
Follow-Up
DAY 2 FOLLOW-UP
LABS: Urinalysis; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide, mesna, and etoposide for 200 minutes.
DAY 3 FOLLOW-UP
LABS: Urinalysis; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide, mesna, and etoposide 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 done locally), Electrolytes,
Glucose, BUN, Creatinine, Total Bilirubin, AST, Alkaline Phosphatase, and Urinalysis; CHEMOTHERAPY ROOM APPOINTMENT:
ifosfamide, mesna, and etoposide for 200 minutes.
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Zztestonc,Jeff J [2507481]
6/13/2017 12:08:40 PM Page 18 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Day 2, Cycle 4 – Planned for 8/16/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Advanced); THERAPY: ifosfamide 1800 mg/m2 IV Day 1, 2, and 3, mesna 600 mg/m2 IV prior to
ifosfamide and 600 mg/m2 by mouth at 4 hours and 8 hours after start of ifosfamide Day 1, 2, and 3; etoposide 100 mg/m2 Day 1, 2,
and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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
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.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Treatment Medications
mesna (MESNEX) 1,176 mg in sodium chloride 0.9 % 50 mL bag
1,176 mg (600 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give prior to start of ifosfamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
ifosfamide (IFEX) 3,530 mg in sodium chloride 0.9 % 250 mL bag
3,530 mg (rounded from 3,528 mg = 1,800 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
etoposide (VEPESID) 196 mg in sodium chloride 0.9 % 500 mL NSS bag
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Zztestonc,Jeff J [2507481]
6/13/2017 12:08:40 PM Page 19 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

196 mg (100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): oral mesna at 4 hours and 8 hours after the
start of ifosfamide (dispensed on Day 1 of each cycle).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 4 – Planned for 8/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Advanced); THERAPY: ifosfamide 1800 mg/m2 IV Day 1, 2, and 3, mesna 600 mg/m2 IV prior to
ifosfamide and 600 mg/m2 by mouth at 4 hours and 8 hours after start of ifosfamide Day 1, 2, and 3; etoposide 100 mg/m2 Day 1, 2,
and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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
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.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
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Zztestonc,Jeff J [2507481]
6/13/2017 12:08:40 PM Page 20 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Medications
mesna (MESNEX) 1,176 mg in sodium chloride 0.9 % 50 mL bag
1,176 mg (600 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give prior to start of ifosfamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
ifosfamide (IFEX) 3,530 mg in sodium chloride 0.9 % 250 mL bag
3,530 mg (rounded from 3,528 mg = 1,800 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
etoposide (VEPESID) 196 mg in sodium chloride 0.9 % 500 mL NSS bag
196 mg (100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): oral mesna at 4 hours and 8 hours after the
start of ifosfamide (dispensed on Day 1 of each cycle).
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 (Advanced); THERAPY: ifosfamide 1800 mg/m2 IV Day 1, 2, and 3, mesna 600 mg/m2 IV prior to
ifosfamide and 600 mg/m2 by mouth at 4 hours and 8 hours after start of ifosfamide Day 1, 2, and 3; etoposide 100 mg/m2 Day 1, 2,
and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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+5 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+5 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 (Advanced); THERAPY: ifosfamide 1800 mg/m2 IV Day 1, 2, and 3, mesna 600 mg/m2 IV prior to
ifosfamide and 600 mg/m2 by mouth at 4 hours and 8 hours after start of ifosfamide Day 1, 2, and 3; etoposide 100 mg/m2 Day 1, 2,
and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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
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Zztestonc,Jeff J [2507481]
6/13/2017 12:08:40 PM Page 21 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Expected-S+12 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+12 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 (Advanced); THERAPY: ifosfamide 1800 mg/m2 IV Day 1, 2, and 3, mesna 600 mg/m2 IV prior to
ifosfamide and 600 mg/m2 by mouth at 4 hours and 8 hours after start of ifosfamide Day 1, 2, and 3; etoposide 100 mg/m2 Day 1, 2,
and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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+19 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+19 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+19 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+19 Approximate, Expires-S+365, Routine
BUN
Expected-S+19 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+19 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+19 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+19 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+19 Approximate, Expires-S+365, Routine
URINALYSIS WITH MICROSCOPY
Expected-S+19 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: CBC, ANC, Urine Heme.
Treatment Parameters
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Zztestonc,Jeff J [2507481]
6/13/2017 12:08:40 PM Page 22 of 42
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
mesna (MESNEX) 1,176 mg in sodium chloride 0.9 % 50 mL bag
1,176 mg (600 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give prior to start of ifosfamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
ifosfamide (IFEX) 3,530 mg in sodium chloride 0.9 % 250 mL bag
3,530 mg (rounded from 3,528 mg = 1,800 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
etoposide (VEPESID) 196 mg in sodium chloride 0.9 % 500 mL NSS bag
196 mg (100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): oral mesna at 4 hours and 8 hours after the
start of ifosfamide (dispensed on Day 1 of each cycle).
Take Home Medications
mesna (MESNEX) 400 MG tab
Take 3 tabs by mouth 2 times daily. Take 4 & 8 hours after start of ifosfamide on Day 1, 2, and 3., 1,200 mg (rounded from 1,176
mg = 600 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S, Local Printer
MD may delete this order and order IV mesna.
Follow-Up
DAY 2 FOLLOW-UP
LABS: Urinalysis; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide, mesna, and etoposide for 200 minutes.
DAY 3 FOLLOW-UP
LABS: Urinalysis; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide, mesna, and etoposide for 200 minutes.
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 15 FOLLOW-UP
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Zztestonc,Jeff J [2507481]
6/13/2017 12:08:40 PM Page 23 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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 done locally), Electrolytes,
Glucose, BUN, Creatinine, Total Bilirubin, AST, Alkaline Phosphatase, and Urinalysis; CHEMOTHERAPY ROOM APPOINTMENT:
ifosfamide, mesna, and etoposide for 200 minutes.
Day 2, Cycle 5 – Planned for 9/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Advanced); THERAPY: ifosfamide 1800 mg/m2 IV Day 1, 2, and 3, mesna 600 mg/m2 IV prior to
ifosfamide and 600 mg/m2 by mouth at 4 hours and 8 hours after start of ifosfamide Day 1, 2, and 3; etoposide 100 mg/m2 Day 1, 2,
and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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
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.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Treatment Medications
mesna (MESNEX) 1,176 mg in sodium chloride 0.9 % 50 mL bag
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Zztestonc,Jeff J [2507481]
6/13/2017 12:08:40 PM Page 24 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

1,176 mg (600 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give prior to start of ifosfamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
ifosfamide (IFEX) 3,530 mg in sodium chloride 0.9 % 250 mL bag
3,530 mg (rounded from 3,528 mg = 1,800 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
etoposide (VEPESID) 196 mg in sodium chloride 0.9 % 500 mL NSS bag
196 mg (100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): oral mesna at 4 hours and 8 hours after the
start of ifosfamide (dispensed on Day 1 of each cycle).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 5 – Planned for 9/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Advanced); THERAPY: ifosfamide 1800 mg/m2 IV Day 1, 2, and 3, mesna 600 mg/m2 IV prior to
ifosfamide and 600 mg/m2 by mouth at 4 hours and 8 hours after start of ifosfamide Day 1, 2, and 3; etoposide 100 mg/m2 Day 1, 2,
and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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
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.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
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Zztestonc,Jeff J [2507481]
6/13/2017 12:08:40 PM Page 25 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Treatment Medications
mesna (MESNEX) 1,176 mg in sodium chloride 0.9 % 50 mL bag
1,176 mg (600 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give prior to start of ifosfamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
ifosfamide (IFEX) 3,530 mg in sodium chloride 0.9 % 250 mL bag
3,530 mg (rounded from 3,528 mg = 1,800 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
etoposide (VEPESID) 196 mg in sodium chloride 0.9 % 500 mL NSS bag
196 mg (100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): oral mesna at 4 hours and 8 hours after the
start of ifosfamide (dispensed on Day 1 of each cycle).
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 (Advanced); THERAPY: ifosfamide 1800 mg/m2 IV Day 1, 2, and 3, mesna 600 mg/m2 IV prior to
ifosfamide and 600 mg/m2 by mouth at 4 hours and 8 hours after start of ifosfamide Day 1, 2, and 3; etoposide 100 mg/m2 Day 1, 2,
and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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+5 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+5 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 (Advanced); THERAPY: ifosfamide 1800 mg/m2 IV Day 1, 2, and 3, mesna 600 mg/m2 IV prior to
ifosfamide and 600 mg/m2 by mouth at 4 hours and 8 hours after start of ifosfamide Day 1, 2, and 3; etoposide 100 mg/m2 Day 1, 2,
and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 cycles or until disease progression.
IV Access
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Zztestonc,Jeff J [2507481]
6/13/2017 12:08:40 PM Page 26 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+12 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+12 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 (Advanced); THERAPY: ifosfamide 1800 mg/m2 IV Day 1, 2, and 3, mesna 600 mg/m2 IV prior to
ifosfamide and 600 mg/m2 by mouth at 4 hours and 8 hours after start of ifosfamide Day 1, 2, and 3; etoposide 100 mg/m2 Day 1, 2,
and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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+19 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+19 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+19 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+19 Approximate, Expires-S+365, Routine
BUN
Expected-S+19 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+19 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+19 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+19 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+19 Approximate, Expires-S+365, Routine
URINALYSIS WITH MICROSCOPY
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Zztestonc,Jeff J [2507481]
6/13/2017 12:08:40 PM Page 27 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Expected-S+19 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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
mesna (MESNEX) 1,176 mg in sodium chloride 0.9 % 50 mL bag
1,176 mg (600 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give prior to start of ifosfamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
ifosfamide (IFEX) 3,530 mg in sodium chloride 0.9 % 250 mL bag
3,530 mg (rounded from 3,528 mg = 1,800 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
etoposide (VEPESID) 196 mg in sodium chloride 0.9 % 500 mL NSS bag
196 mg (100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): oral mesna at 4 hours and 8 hours after the
start of ifosfamide (dispensed on Day 1 of each cycle).
Take Home Medications
mesna (MESNEX) 400 MG tab
Take 3 tabs by mouth 2 times daily. Take 4 & 8 hours after start of ifosfamide on Day 1, 2, and 3., 1,200 mg (rounded from 1,176
mg = 600 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S, Local Printer
MD may delete this order and order IV mesna.
Follow-Up
DAY 2 FOLLOW-UP
LABS: Urinalysis; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide, mesna, and etoposide for 200 minutes.
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Zztestonc,Jeff J [2507481]
6/13/2017 12:08:40 PM Page 28 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

DAY 3 FOLLOW-UP
LABS: Urinalysis; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide, mesna, and etoposide 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 done locally), Electrolytes,
Glucose, BUN, Creatinine, Total Bilirubin, AST, Alkaline Phosphatase, and Urinalysis; CHEMOTHERAPY ROOM APPOINTMENT:
ifosfamide, mesna, and etoposide for 200 minutes.
Day 2, Cycle 6 – Planned for 9/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Advanced); THERAPY: ifosfamide 1800 mg/m2 IV Day 1, 2, and 3, mesna 600 mg/m2 IV prior to
ifosfamide and 600 mg/m2 by mouth at 4 hours and 8 hours after start of ifosfamide Day 1, 2, and 3; etoposide 100 mg/m2 Day 1, 2,
and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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
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.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Hydration
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Zztestonc,Jeff J [2507481]
6/13/2017 12:08:40 PM Page 29 of 42
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.
Treatment Medications
mesna (MESNEX) 1,176 mg in sodium chloride 0.9 % 50 mL bag
1,176 mg (600 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give prior to start of ifosfamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
ifosfamide (IFEX) 3,530 mg in sodium chloride 0.9 % 250 mL bag
3,530 mg (rounded from 3,528 mg = 1,800 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
etoposide (VEPESID) 196 mg in sodium chloride 0.9 % 500 mL NSS bag
196 mg (100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): oral mesna at 4 hours and 8 hours after the
start of ifosfamide (dispensed on Day 1 of each cycle).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 6 – Planned for 9/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Advanced); THERAPY: ifosfamide 1800 mg/m2 IV Day 1, 2, and 3, mesna 600 mg/m2 IV prior to
ifosfamide and 600 mg/m2 by mouth at 4 hours and 8 hours after start of ifosfamide Day 1, 2, and 3; etoposide 100 mg/m2 Day 1, 2,
and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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
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 12:08:40 PM Page 30 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Treatment Medications
mesna (MESNEX) 1,176 mg in sodium chloride 0.9 % 50 mL bag
1,176 mg (600 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give prior to start of ifosfamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
ifosfamide (IFEX) 3,530 mg in sodium chloride 0.9 % 250 mL bag
3,530 mg (rounded from 3,528 mg = 1,800 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
etoposide (VEPESID) 196 mg in sodium chloride 0.9 % 500 mL NSS bag
196 mg (100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): oral mesna at 4 hours and 8 hours after the
start of ifosfamide (dispensed on Day 1 of each cycle).
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 (Advanced); THERAPY: ifosfamide 1800 mg/m2 IV Day 1, 2, and 3, mesna 600 mg/m2 IV prior to
ifosfamide and 600 mg/m2 by mouth at 4 hours and 8 hours after start of ifosfamide Day 1, 2, and 3; etoposide 100 mg/m2 Day 1, 2,
and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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+5 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+5 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
Treatment Plan Information
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Zztestonc,Jeff J [2507481]
6/13/2017 12:08:40 PM Page 31 of 42
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 (Advanced); THERAPY: ifosfamide 1800 mg/m2 IV Day 1, 2, and 3, mesna 600 mg/m2 IV prior to
ifosfamide and 600 mg/m2 by mouth at 4 hours and 8 hours after start of ifosfamide Day 1, 2, and 3; etoposide 100 mg/m2 Day 1, 2,
and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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+12 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+12 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 7 – 10/17/2017 through 11/6/2017 (21 days), Planned
Day 1, Cycle 7 – Planned for 10/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Advanced); THERAPY: ifosfamide 1800 mg/m2 IV Day 1, 2, and 3, mesna 600 mg/m2 IV prior to
ifosfamide and 600 mg/m2 by mouth at 4 hours and 8 hours after start of ifosfamide Day 1, 2, and 3; etoposide 100 mg/m2 Day 1, 2,
and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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+19 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+19 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+19 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+19 Approximate, Expires-S+365, Routine
BUN
Expected-S+19 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+19 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+19 Approximate, Expires-S+365, Routine
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Zztestonc,Jeff J [2507481]
6/13/2017 12:08:40 PM Page 32 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

AST/SGOT
Expected-S+19 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+19 Approximate, Expires-S+365, Routine
URINALYSIS WITH MICROSCOPY
Expected-S+19 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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
mesna (MESNEX) 1,176 mg in sodium chloride 0.9 % 50 mL bag
1,176 mg (600 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give prior to start of ifosfamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
ifosfamide (IFEX) 3,530 mg in sodium chloride 0.9 % 250 mL bag
3,530 mg (rounded from 3,528 mg = 1,800 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
etoposide (VEPESID) 196 mg in sodium chloride 0.9 % 500 mL NSS bag
196 mg (100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): oral mesna at 4 hours and 8 hours after the
start of ifosfamide (dispensed on Day 1 of each cycle).
Take Home Medications
mesna (MESNEX) 400 MG tab
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Zztestonc,Jeff J [2507481]
6/13/2017 12:08:40 PM Page 33 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Take 3 tabs by mouth 2 times daily. Take 4 & 8 hours after start of ifosfamide on Day 1, 2, and 3., 1,200 mg (rounded from 1,176
mg = 600 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S, Local Printer
MD may delete this order and order IV mesna.
Follow-Up
DAY 2 FOLLOW-UP
LABS: Urinalysis; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide, mesna, and etoposide for 200 minutes.
DAY 3 FOLLOW-UP
LABS: Urinalysis; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide, mesna, and etoposide 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 done locally), Electrolytes,
Glucose, BUN, Creatinine, Total Bilirubin, AST, Alkaline Phosphatase, and Urinalysis; CHEMOTHERAPY ROOM APPOINTMENT:
ifosfamide, mesna, and etoposide for 200 minutes.
Day 2, Cycle 7 – Planned for 10/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Advanced); THERAPY: ifosfamide 1800 mg/m2 IV Day 1, 2, and 3, mesna 600 mg/m2 IV prior to
ifosfamide and 600 mg/m2 by mouth at 4 hours and 8 hours after start of ifosfamide Day 1, 2, and 3; etoposide 100 mg/m2 Day 1, 2,
and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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
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.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
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Zztestonc,Jeff J [2507481]
6/13/2017 12:08:40 PM Page 34 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Treatment Medications
mesna (MESNEX) 1,176 mg in sodium chloride 0.9 % 50 mL bag
1,176 mg (600 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give prior to start of ifosfamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
ifosfamide (IFEX) 3,530 mg in sodium chloride 0.9 % 250 mL bag
3,530 mg (rounded from 3,528 mg = 1,800 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
etoposide (VEPESID) 196 mg in sodium chloride 0.9 % 500 mL NSS bag
196 mg (100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): oral mesna at 4 hours and 8 hours after the
start of ifosfamide (dispensed on Day 1 of each cycle).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 7 – Planned for 10/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Advanced); THERAPY: ifosfamide 1800 mg/m2 IV Day 1, 2, and 3, mesna 600 mg/m2 IV prior to
ifosfamide and 600 mg/m2 by mouth at 4 hours and 8 hours after start of ifosfamide Day 1, 2, and 3; etoposide 100 mg/m2 Day 1, 2,
and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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
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.
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Zztestonc,Jeff J [2507481]
6/13/2017 12:08:40 PM Page 35 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Treatment Medications
mesna (MESNEX) 1,176 mg in sodium chloride 0.9 % 50 mL bag
1,176 mg (600 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give prior to start of ifosfamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
ifosfamide (IFEX) 3,530 mg in sodium chloride 0.9 % 250 mL bag
3,530 mg (rounded from 3,528 mg = 1,800 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
etoposide (VEPESID) 196 mg in sodium chloride 0.9 % 500 mL NSS bag
196 mg (100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): oral mesna at 4 hours and 8 hours after the
start of ifosfamide (dispensed on Day 1 of each cycle).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 8, Cycle 7 – Planned for 10/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Advanced); THERAPY: ifosfamide 1800 mg/m2 IV Day 1, 2, and 3, mesna 600 mg/m2 IV prior to
ifosfamide and 600 mg/m2 by mouth at 4 hours and 8 hours after start of ifosfamide Day 1, 2, and 3; etoposide 100 mg/m2 Day 1, 2,
and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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+5 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+5 Approximate, Expires-S+365, Routine
Follow-Up
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Zztestonc,Jeff J [2507481]
6/13/2017 12:08:40 PM Page 36 of 42
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 7 – Planned for 10/31/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Advanced); THERAPY: ifosfamide 1800 mg/m2 IV Day 1, 2, and 3, mesna 600 mg/m2 IV prior to
ifosfamide and 600 mg/m2 by mouth at 4 hours and 8 hours after start of ifosfamide Day 1, 2, and 3; etoposide 100 mg/m2 Day 1, 2,
and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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+12 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+12 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 8 – 11/7/2017 through 11/27/2017 (21 days), Planned
Day 1, Cycle 8 – Planned for 11/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Advanced); THERAPY: ifosfamide 1800 mg/m2 IV Day 1, 2, and 3, mesna 600 mg/m2 IV prior to
ifosfamide and 600 mg/m2 by mouth at 4 hours and 8 hours after start of ifosfamide Day 1, 2, and 3; etoposide 100 mg/m2 Day 1, 2,
and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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+19 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+19 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+19 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+19 Approximate, Expires-S+365, Routine
BUN
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Zztestonc,Jeff J [2507481]
6/13/2017 12:08:40 PM Page 37 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Expected-S+19 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+19 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+19 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+19 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+19 Approximate, Expires-S+365, Routine
URINALYSIS WITH MICROSCOPY
Expected-S+19 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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
mesna (MESNEX) 1,176 mg in sodium chloride 0.9 % 50 mL bag
1,176 mg (600 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give prior to start of ifosfamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
ifosfamide (IFEX) 3,530 mg in sodium chloride 0.9 % 250 mL bag
3,530 mg (rounded from 3,528 mg = 1,800 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
etoposide (VEPESID) 196 mg in sodium chloride 0.9 % 500 mL NSS bag
196 mg (100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
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Zztestonc,Jeff J [2507481]
6/13/2017 12:08:40 PM Page 38 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): oral mesna at 4 hours and 8
hours after the start of ifosfamide (dispensed on Day 1 of each cycle).
Take Home Medications
mesna (MESNEX) 400 MG tab
Take 3 tabs by mouth 2 times daily. Take 4 & 8 hours after start of ifosfamide on Day 1, 2, and 3., 1,200 mg (rounded from 1,176
mg = 600 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S, Local Printer
MD may delete this order and order IV mesna.
Follow-Up
DAY 2 FOLLOW-UP
LABS: Urinalysis; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide, mesna, and etoposide for 200 minutes.
DAY 3 FOLLOW-UP
LABS: Urinalysis; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide, mesna, and etoposide 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 done locally), Electrolytes,
Glucose, BUN, Creatinine, Total Bilirubin, AST, Alkaline Phosphatase, and Urinalysis; CHEMOTHERAPY ROOM APPOINTMENT:
ifosfamide, mesna, and etoposide for 200 minutes.
Day 2, Cycle 8 – Planned for 11/8/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Advanced); THERAPY: ifosfamide 1800 mg/m2 IV Day 1, 2, and 3, mesna 600 mg/m2 IV prior to
ifosfamide and 600 mg/m2 by mouth at 4 hours and 8 hours after start of ifosfamide Day 1, 2, and 3; etoposide 100 mg/m2 Day 1, 2,
and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
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Zztestonc,Jeff J [2507481]
6/13/2017 12:08:40 PM Page 39 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Treatment Medications
mesna (MESNEX) 1,176 mg in sodium chloride 0.9 % 50 mL bag
1,176 mg (600 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give prior to start of ifosfamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
ifosfamide (IFEX) 3,530 mg in sodium chloride 0.9 % 250 mL bag
3,530 mg (rounded from 3,528 mg = 1,800 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
etoposide (VEPESID) 196 mg in sodium chloride 0.9 % 500 mL NSS bag
196 mg (100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): oral mesna at 4 hours and 8 hours after the
start of ifosfamide (dispensed on Day 1 of each cycle).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 8 – Planned for 11/9/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Advanced); THERAPY: ifosfamide 1800 mg/m2 IV Day 1, 2, and 3, mesna 600 mg/m2 IV prior to
ifosfamide and 600 mg/m2 by mouth at 4 hours and 8 hours after start of ifosfamide Day 1, 2, and 3; etoposide 100 mg/m2 Day 1, 2,
and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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
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Zztestonc,Jeff J [2507481]
6/13/2017 12:08:40 PM Page 40 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Treatment Medications
mesna (MESNEX) 1,176 mg in sodium chloride 0.9 % 50 mL bag
1,176 mg (600 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give prior to start of ifosfamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
ifosfamide (IFEX) 3,530 mg in sodium chloride 0.9 % 250 mL bag
3,530 mg (rounded from 3,528 mg = 1,800 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
etoposide (VEPESID) 196 mg in sodium chloride 0.9 % 500 mL NSS bag
196 mg (100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): oral mesna at 4 hours and 8 hours after the
start of ifosfamide (dispensed on Day 1 of each cycle).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 8, Cycle 8 – Planned for 11/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Advanced); THERAPY: ifosfamide 1800 mg/m2 IV Day 1, 2, and 3, mesna 600 mg/m2 IV prior to
ifosfamide and 600 mg/m2 by mouth at 4 hours and 8 hours after start of ifosfamide Day 1, 2, and 3; etoposide 100 mg/m2 Day 1, 2,
and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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
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Zztestonc,Jeff J [2507481]
6/13/2017 12:08:40 PM Page 41 of 42
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+5 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+5 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 8 – Planned for 11/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Advanced); THERAPY: ifosfamide 1800 mg/m2 IV Day 1, 2, and 3, mesna 600 mg/m2 IV prior to
ifosfamide and 600 mg/m2 by mouth at 4 hours and 8 hours after start of ifosfamide Day 1, 2, and 3; etoposide 100 mg/m2 Day 1, 2,
and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 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+12 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+12 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 12:08:40 PM Page 42 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org