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

/clinical/cckm-tools/content/beacon-protocols/sarcoma/name-97006-en.cckm

201706165

page

100

UWHC,UWMF,

Tools,

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

CSC Sarcoma Etoposide(21D:1-5) Ifosfamide(21D:1-5) VER 5-1-17 (HL 960)

CSC Sarcoma Etoposide(21D:1-5) Ifosfamide(21D:1-5) VER 5-1-17 (HL 960) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Sarcoma


CSC SARCOMA ETOPOSIDE(21D1-5)IFOSFAMIDE(21D1-5) VER 5-1-17 (HL 960) – Properties
Pre-Cycle – 6/6/2017 through 6/12/2017 (7 days), Planned
Day 1, Pre-Cycle – Planned for 6/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S Approximate, Expires-S+365, Routine
BUN
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S Approximate, Expires-S+365, Routine
URINALYSIS WITH MICROSCOPY
Expected-S Approximate, Expires-S+365, Routine
Take Home Medications
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 1 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Inject 480 mcg under skin one time daily in evening. Begin Day ***. Continue until ANC is greater than *** after nadir., 480 mcg,
Disp-10 Syringe, R-5, 1 X DAILY (PM) starting S, Local Printer
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
Cycle 1 – 6/13/2017 through 7/3/2017 (21 days), Planned
Day 1, Cycle 1 – Planned for 6/13/2017
Treatment Plan Information
Reference Information (1)
SARCOMA: Meyer WH, et al. J Clin Oncol 1992;10:1737-42.
Reference Information (2)
SARCOMA: Kung FH, et al. Cancer 1993;71:1898-903.
Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: CBC, ANC, Urine Heme.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1500/µL or Platelets less than or equal to 100K/µL or Urine
Hemoglobin greater than Trace.
Nursing Procedure, Assessment and Monitoring
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.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 2 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
mesna (MESNEX) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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.
Take Home Medications
mesna (MESNEX) 400 MG tab
Take 2 tabs by mouth 2 times daily. Take 4 & 8 hours after start of ifosfamide Day 1 thru 5, 800 mg (rounded from 784 mg = 400
mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-5, 2 X DAILY starting S
MD may delete this order and order IV mesna.
Follow-Up
DAY 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 4 FOLLOW-UP
LABS: Urinalysis; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide, mesna and etoposide for 200 minutes.
DAY 5 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, Cr, T BILI, AST, Alk Phos, 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: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
URINALYSIS WITH MICROSCOPY
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 3 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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.
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: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 4 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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.
Follow-Up
VERIFY APPOINTMENTS
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 5 of 90
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 4, Cycle 1 – Planned for 6/16/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 6 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 1 – Planned for 6/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 7 of 90
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.
Treatment Medications
mesna (MESNEX) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 8, Cycle 1 – Planned for 6/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+3 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+3 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 1 – Planned for 6/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 8 of 90
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+10 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+10 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 7/4/2017 through 7/24/2017 (21 days), Planned
Day 1, Cycle 2 – Planned for 7/4/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+17 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+17 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+17 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+17 Approximate, Expires-S+365, Routine
BUN
Expected-S+17 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+17 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+17 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+17 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+17 Approximate, Expires-S+365, Routine
URINALYSIS WITH MICROSCOPY
Expected-S+17 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 9 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Verify pretreatment labs have been obtained and resulted: CBC, ANC, Urine Heme.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1500/µL or Platelets less than or equal to 100K/µL or Urine
Hemoglobin greater than Trace.
Nursing Procedure, Assessment and Monitoring
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) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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.
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 4 FOLLOW-UP
LABS: Urinalysis; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide, mesna and etoposide for 200 minutes.
DAY 5 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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 10 of 90
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, Cr, T BILI, AST, Alk Phos, 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: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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) in sodium chloride 0.9 % 50 mL bag
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 11 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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.
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
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 12 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 4, Cycle 2 – Planned for 7/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 13 of 90
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) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 2 – Planned for 7/8/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 14 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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.
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: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+3 Approximate, Expires-S+365, Routine
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 15 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

ABSOLUTE NEUTROPHIL COUNT
Expected-S+3 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: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+10 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+10 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 – 7/25/2017 through 8/14/2017 (21 days), Planned
Day 1, Cycle 3 – Planned for 7/25/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+17 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+17 Approximate, Expires-S+365, Routine
ELECTROLYTES
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 16 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Expected-S+17 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+17 Approximate, Expires-S+365, Routine
BUN
Expected-S+17 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+17 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+17 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+17 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+17 Approximate, Expires-S+365, Routine
URINALYSIS WITH MICROSCOPY
Expected-S+17 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) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 17 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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.
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 4 FOLLOW-UP
LABS: Urinalysis; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide, mesna and etoposide for 200 minutes.
DAY 5 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, Cr, T BILI, AST, Alk Phos, 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: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 18 of 90
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.
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) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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.
Follow-Up
VERIFY APPOINTMENTS
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: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 19 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 4, Cycle 3 – Planned for 7/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 20 of 90
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) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 3 – Planned for 7/29/2017
Treatment Plan Information
Treatment Plan Summary
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 21 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 22 of 90
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 3 – Planned for 8/1/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+3 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+3 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 3 – Planned for 8/8/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+10 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+10 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 – 8/15/2017 through 9/4/2017 (21 days), Planned
Day 1, Cycle 4 – Planned for 8/15/2017
Treatment Plan Information
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 23 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+17 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+17 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+17 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+17 Approximate, Expires-S+365, Routine
BUN
Expected-S+17 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+17 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+17 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+17 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+17 Approximate, Expires-S+365, Routine
URINALYSIS WITH MICROSCOPY
Expected-S+17 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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 24 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 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) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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.
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 4 FOLLOW-UP
LABS: Urinalysis; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide, mesna and etoposide for 200 minutes.
DAY 5 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, Cr, T BILI, AST, Alk Phos, and Urinalysis; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide, mesna and
etoposide for 200 minutes.
Day 2, Cycle 4 – Planned for 8/16/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 25 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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.
Follow-Up
VERIFY APPOINTMENTS
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 26 of 90
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 4 – Planned for 8/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 27 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 4, Cycle 4 – Planned for 8/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 28 of 90
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.
Treatment Medications
mesna (MESNEX) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 4 – Planned for 8/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 29 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
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) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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.
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: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+3 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+3 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 4 – Planned for 8/29/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 30 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+10 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+10 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: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+17 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+17 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+17 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+17 Approximate, Expires-S+365, Routine
BUN
Expected-S+17 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+17 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+17 Approximate, Expires-S+365, Routine
AST/SGOT
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 31 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Expected-S+17 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+17 Approximate, Expires-S+365, Routine
URINALYSIS WITH MICROSCOPY
Expected-S+17 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) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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.
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.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 32 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

DAY 4 FOLLOW-UP
LABS: Urinalysis; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide, mesna and etoposide for 200 minutes.
DAY 5 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, Cr, T BILI, AST, Alk Phos, 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: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 33 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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.
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: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 34 of 90
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) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 4, Cycle 5 – Planned for 9/8/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 35 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 5 – Planned for 9/9/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
URINALYSIS WITH MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Routine
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 36 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: 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) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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.
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: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 37 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+3 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+3 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 5 – Planned for 9/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+10 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+10 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 6 – 9/26/2017 through 10/16/2017 (21 days), Planned
Day 1, Cycle 6 – Planned for 9/26/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 38 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+17 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+17 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+17 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+17 Approximate, Expires-S+365, Routine
BUN
Expected-S+17 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+17 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+17 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+17 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+17 Approximate, Expires-S+365, Routine
URINALYSIS WITH MICROSCOPY
Expected-S+17 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.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 39 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
mesna (MESNEX) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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.
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 4 FOLLOW-UP
LABS: Urinalysis; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide, mesna and etoposide for 200 minutes.
DAY 5 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, Cr, T BILI, AST, Alk Phos, 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: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 40 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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.
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: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 41 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
URINALYSIS WITH MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: Urine Heme.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Urine Hemoglobin greater than Trace.
Nursing Procedure, Assessment and Monitoring
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) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 4, Cycle 6 – Planned for 9/29/2017
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 42 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 43 of 90
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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 6 – Planned for 9/30/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 44 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

mesna (MESNEX) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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.
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: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+3 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+3 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
Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 45 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Expected-S+10 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+10 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: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+17 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+17 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+17 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+17 Approximate, Expires-S+365, Routine
BUN
Expected-S+17 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+17 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+17 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+17 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+17 Approximate, Expires-S+365, Routine
URINALYSIS WITH MICROSCOPY
Expected-S+17 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: CBC, ANC, Urine Heme.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 46 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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.
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 4 FOLLOW-UP
LABS: Urinalysis; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide, mesna and etoposide for 200 minutes.
DAY 5 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).
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 47 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally),
Electrolytes, Glucose, BUN, Cr, T BILI, AST, Alk Phos, 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: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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) in sodium chloride 0.9 % 50 mL bag
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 48 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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.
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: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 49 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 4, Cycle 7 – Planned for 10/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 50 of 90
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) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 7 – Planned for 10/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 51 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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.
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: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+3 Approximate, Expires-S+365, Routine
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 52 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

ABSOLUTE NEUTROPHIL COUNT
Expected-S+3 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 7 – Planned for 10/31/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+10 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+10 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: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+17 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+17 Approximate, Expires-S+365, Routine
ELECTROLYTES
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 53 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Expected-S+17 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+17 Approximate, Expires-S+365, Routine
BUN
Expected-S+17 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+17 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+17 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+17 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+17 Approximate, Expires-S+365, Routine
URINALYSIS WITH MICROSCOPY
Expected-S+17 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) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 54 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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.
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 4 FOLLOW-UP
LABS: Urinalysis; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide, mesna and etoposide for 200 minutes.
DAY 5 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, Cr, T BILI, AST, Alk Phos, 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: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 55 of 90
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.
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) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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.
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: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 56 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 4, Cycle 8 – Planned for 11/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 57 of 90
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) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 8 – Planned for 11/11/2017
Treatment Plan Information
Treatment Plan Summary
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 58 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 59 of 90
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 8 – Planned for 11/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+3 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+3 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: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+10 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+10 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 9 – 11/28/2017 through 12/18/2017 (21 days), Planned
Day 1, Cycle 9 – Planned for 11/28/2017
Treatment Plan Information
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 60 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+17 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+17 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+17 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+17 Approximate, Expires-S+365, Routine
BUN
Expected-S+17 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+17 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+17 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+17 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+17 Approximate, Expires-S+365, Routine
URINALYSIS WITH MICROSCOPY
Expected-S+17 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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 61 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 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) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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.
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 4 FOLLOW-UP
LABS: Urinalysis; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide, mesna and etoposide for 200 minutes.
DAY 5 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, Cr, T BILI, AST, Alk Phos, and Urinalysis; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide, mesna and
etoposide for 200 minutes.
Day 2, Cycle 9 – Planned for 11/29/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 62 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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.
Follow-Up
VERIFY APPOINTMENTS
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 63 of 90
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 9 – Planned for 11/30/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 64 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 4, Cycle 9 – Planned for 12/1/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 65 of 90
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.
Treatment Medications
mesna (MESNEX) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 9 – Planned for 12/2/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 66 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
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) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 8, Cycle 9 – Planned for 12/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+3 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+3 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 9 – Planned for 12/12/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 67 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+10 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+10 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 10 – 12/19/2017 through 1/8/2018 (21 days), Planned
Day 1, Cycle 10 – Planned for 12/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+17 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+17 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+17 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+17 Approximate, Expires-S+365, Routine
BUN
Expected-S+17 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+17 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+17 Approximate, Expires-S+365, Routine
AST/SGOT
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 68 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Expected-S+17 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+17 Approximate, Expires-S+365, Routine
URINALYSIS WITH MICROSCOPY
Expected-S+17 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) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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.
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.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 69 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

DAY 4 FOLLOW-UP
LABS: Urinalysis; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide, mesna and etoposide for 200 minutes.
DAY 5 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, Cr, T BILI, AST, Alk Phos, and Urinalysis; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide, mesna and
etoposide for 200 minutes.
Day 2, Cycle 10 – Planned for 12/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 70 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 10 – Planned for 12/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 71 of 90
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) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 4, Cycle 10 – Planned for 12/22/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 72 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 10 – Planned for 12/23/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
URINALYSIS WITH MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Routine
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 73 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: 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) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 8, Cycle 10 – Planned for 12/26/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 74 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+3 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+3 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 10 – Planned for 1/2/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+10 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+10 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 11 – 1/9/2018 through 1/29/2018 (21 days), Planned
Day 1, Cycle 11 – Planned for 1/9/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 75 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+17 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+17 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+17 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+17 Approximate, Expires-S+365, Routine
BUN
Expected-S+17 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+17 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+17 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+17 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+17 Approximate, Expires-S+365, Routine
URINALYSIS WITH MICROSCOPY
Expected-S+17 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.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 76 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
mesna (MESNEX) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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.
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 4 FOLLOW-UP
LABS: Urinalysis; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide, mesna and etoposide for 200 minutes.
DAY 5 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, Cr, T BILI, AST, Alk Phos, and Urinalysis; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide, mesna and
etoposide for 200 minutes.
Day 2, Cycle 11 – Planned for 1/10/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 77 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 11 – Planned for 1/11/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 78 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
URINALYSIS WITH MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: Urine Heme.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Urine Hemoglobin greater than Trace.
Nursing Procedure, Assessment and Monitoring
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) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 4, Cycle 11 – Planned for 1/12/2018
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 79 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 80 of 90
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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 11 – Planned for 1/13/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 81 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

mesna (MESNEX) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 8, Cycle 11 – Planned for 1/16/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+3 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+3 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 11 – Planned for 1/23/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 82 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Expected-S+10 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+10 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 12 – 1/30/2018 through 2/19/2018 (21 days), Planned
Day 1, Cycle 12 – Planned for 1/30/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+17 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+17 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+17 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+17 Approximate, Expires-S+365, Routine
BUN
Expected-S+17 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+17 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+17 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+17 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+17 Approximate, Expires-S+365, Routine
URINALYSIS WITH MICROSCOPY
Expected-S+17 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: CBC, ANC, Urine Heme.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 83 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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.
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 4 FOLLOW-UP
LABS: Urinalysis; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide, mesna and etoposide for 200 minutes.
DAY 5 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).
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 84 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally),
Electrolytes, Glucose, BUN, Cr, T BILI, AST, Alk Phos, and Urinalysis; CHEMOTHERAPY ROOM APPOINTMENT:
ifosfamide, mesna and etoposide for 200 minutes.
Day 2, Cycle 12 – Planned for 1/31/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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) in sodium chloride 0.9 % 50 mL bag
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 85 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 12 – Planned for 2/1/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 86 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 4, Cycle 12 – Planned for 2/2/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 87 of 90
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) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 12 – Planned for 2/3/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 88 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
Mesna total dose matching dose of ifosfamide divided into 3 doses with the first dose administered IV just prior to ifosfamide and
then PO or IV at 4 hours and 8 hours after the start of ifosfamide daily on Days 1 through 5.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 8, Cycle 12 – Planned for 2/6/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+3 Approximate, Expires-S+365, Routine
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 89 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

ABSOLUTE NEUTROPHIL COUNT
Expected-S+3 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 12 – Planned for 2/13/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma; THERAPY: ifosfamide 1600-2000 mg/m2/day IV Day 1 through 5, mesna (matching dose of
ifosfamide divided into 3 doses) 534-667 mg/m2 IV prior to ifosfamide and PO/IV at 4 hours and 8 hours after start of ifosfamide Day
1 through 5; etoposide 100 mg/m2/day Day 1 through 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE:
6-12 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+10 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+10 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
6/13/2017 12:17:14 PM Page 90 of 90
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org