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CSC Sarcoma Irinotecan(21D:1-5,8-12) Temozolomide(21D:1-5) VER 5-24-17 (HL 3378)

CSC Sarcoma Irinotecan(21D:1-5,8-12) Temozolomide(21D:1-5) VER 5-24-17 (HL 3378) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Sarcoma


CSC SARCOMA IRINOTECAN(21D1-5,8-12)TEMOZOLOMIDE(21D1-5) VER 5-24-17 (HL 3378) – 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 Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S Approximate, Expires-S+365, Routine
BUN
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
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
loperamide 2 MG cap
Take 2 tab by mouth with 1st loose stool followed by 1 tab every 2h or 2 tab every 4h until no diarrhea x12h. Max dose=8 tab/day,
Disp-30 cap, R-5, starting S, Local Printer
Counsel patient to purchase over the counter if not covered by insurance and provide instructions for use.
Cycle 1 – 6/13/2017 through 7/3/2017 (21 days), Planned
Day 1, Cycle 1 – Planned for 6/13/2017
Treatment Plan Information
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 1 of 67
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Reference Information (1)
EWING SARCOMA: Wagner LM, et al Pediatr Blood Cancer 2007;48(2):132-9.
Reference Information (2)
EWING SARCOMA: Casey DA, et al. Pediatr Blood Cancer 2009;53(6):1029-34.
Treatment Plan Summary
DISEASE: Ewing Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets and Hemoglobin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL or
Hemoglobin less than 8 g/dL.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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
temozolomide (TEMODAR) cap 195 mg
195 mg (rounded from 196 mg = 100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Administer at least one (1) hours prior to irinotecan infusion.
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 2 of 67
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: temozolomide and irinotecan for 180 minutes.
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: temozolomide and irinotecan for 180 minutes.
DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: temozolomide and irinotecan for 180 minutes.
DAY 5 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: temozolomide and irinotecan for 180 minutes.
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: irinotecan for 150 minutes.
DAY 9 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: irinotecan for 150 minutes.
DAY 10 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: irinotecan for 150 minutes.
DAY 11 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: irinotecan for 150 minutes.
DAY 12 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: irinotecan for 150 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Electrolytes,
Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT:
temozolomide and irinotecan for 180 minutes.
Day 2, Cycle 1 – Planned for 6/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 3 of 67
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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
temozolomide (TEMODAR) cap 195 mg
195 mg (rounded from 196 mg = 100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Administer at least one (1) hours prior to irinotecan infusion.
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
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 Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 4 of 67
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 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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
temozolomide (TEMODAR) cap 195 mg
195 mg (rounded from 196 mg = 100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Administer at least one (1) hours prior to irinotecan infusion.
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
Follow-Up
VERIFY APPOINTMENTS
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 Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 5 of 67
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
temozolomide (TEMODAR) cap 195 mg
195 mg (rounded from 196 mg = 100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Administer at least one (1) hours prior to irinotecan infusion.
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
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 Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 6 of 67
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
temozolomide (TEMODAR) cap 195 mg
195 mg (rounded from 196 mg = 100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Administer at least one (1) hours prior to irinotecan infusion.
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 1 – Planned for 6/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+3 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+3 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets and Hemoglobin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL or
Hemoglobin less than 8 g/dL.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 7 of 67
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 9, Cycle 1 – Planned for 6/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
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
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 8 of 67
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 10, Cycle 1 – Planned for 6/22/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 9 of 67
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
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 11, Cycle 1 – Planned for 6/23/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 10 of 67
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side
effects, Administer over 1 Minutes
May repeat x1 dose.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 12, Cycle 1 – Planned for 6/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 11 of 67
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Day 15 - Lab Only, Cycle 1 – Planned for 6/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+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.
Cycle 2 – 7/4/2017 through 7/24/2017 (21 days), Planned
Day 1, Cycle 2 – Planned for 7/4/2017
Treatment Plan Information
Reference Information (1)
EWING SARCOMA: Wagner LM, et al Pediatr Blood Cancer 2007;48(2):132-9.
Reference Information (2)
EWING SARCOMA: Casey DA, et al. Pediatr Blood Cancer 2009;53(6):1029-34.
Treatment Plan Summary
DISEASE: Ewing Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+10 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+10 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+10 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+10 Approximate, Expires-S+365, Routine
BUN
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 12 of 67
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
CREATININE
Expected-S+10 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+10 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+10 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+10 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+10 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets and Hemoglobin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL or
Hemoglobin less than 8 g/dL.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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
temozolomide (TEMODAR) cap 195 mg
195 mg (rounded from 196 mg = 100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Administer at least one (1) hours prior to irinotecan infusion.
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 13 of 67
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: temozolomide and irinotecan for 180 minutes.
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: temozolomide and irinotecan for 180 minutes.
DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: temozolomide and irinotecan for 180 minutes.
DAY 5 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: temozolomide and irinotecan for 180 minutes.
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: irinotecan for 150 minutes.
DAY 9 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: irinotecan for 150 minutes.
DAY 10 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: irinotecan for 150 minutes.
DAY 11 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: irinotecan for 150 minutes.
DAY 12 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: irinotecan for 150 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Electrolytes,
Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT:
temozolomide and irinotecan for 180 minutes.
Day 2, Cycle 2 – Planned for 7/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 14 of 67
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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
temozolomide (TEMODAR) cap 195 mg
195 mg (rounded from 196 mg = 100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Administer at least one (1) hours prior to irinotecan infusion.
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
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 Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 15 of 67
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
temozolomide (TEMODAR) cap 195 mg
195 mg (rounded from 196 mg = 100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Administer at least one (1) hours prior to irinotecan infusion.
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
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 Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 16 of 67
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
temozolomide (TEMODAR) cap 195 mg
195 mg (rounded from 196 mg = 100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Administer at least one (1) hours prior to irinotecan infusion.
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
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 Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 17 of 67
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

temozolomide (TEMODAR) cap 195 mg
195 mg (rounded from 196 mg = 100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Administer at least one (1) hours prior to irinotecan infusion.
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 2 – Planned for 7/11/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+3 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+3 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets and Hemoglobin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL or
Hemoglobin less than 8 g/dL.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 18 of 67
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 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 9, Cycle 2 – Planned for 7/12/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 19 of 67
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
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 10, Cycle 2 – Planned for 7/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 20 of 67
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
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 11, Cycle 2 – Planned for 7/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 21 of 67
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.
Day 12, Cycle 2 – Planned for 7/15/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15 - Lab Only, Cycle 2 – Planned for 7/16/2017
Treatment Plan Information
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 22 of 67
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 Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8
through 12, temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until
disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+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.
Cycle 3 – 7/25/2017 through 8/14/2017 (21 days), Planned
Day 1, Cycle 3 – Planned for 7/25/2017
Treatment Plan Information
Reference Information (1)
EWING SARCOMA: Wagner LM, et al Pediatr Blood Cancer 2007;48(2):132-9.
Reference Information (2)
EWING SARCOMA: Casey DA, et al. Pediatr Blood Cancer 2009;53(6):1029-34.
Treatment Plan Summary
DISEASE: Ewing Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+10 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+10 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+10 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+10 Approximate, Expires-S+365, Routine
BUN
Expected-S+10 Approximate, Expires-S+365, Routine
CREATININE
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 23 of 67
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
BILIRUBIN, TOTAL
Expected-S+10 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+10 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+10 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+10 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets and Hemoglobin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL or
Hemoglobin less than 8 g/dL.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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
temozolomide (TEMODAR) cap 195 mg
195 mg (rounded from 196 mg = 100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Administer at least one (1) hours prior to irinotecan infusion.
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 24 of 67
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: temozolomide and irinotecan for 180 minutes.
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: temozolomide and irinotecan for 180 minutes.
DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: temozolomide and irinotecan for 180 minutes.
DAY 5 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: temozolomide and irinotecan for 180 minutes.
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: irinotecan for 150 minutes.
DAY 9 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: irinotecan for 150 minutes.
DAY 10 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: irinotecan for 150 minutes.
DAY 11 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: irinotecan for 150 minutes.
DAY 12 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: irinotecan for 150 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Electrolytes,
Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT:
temozolomide and irinotecan for 180 minutes.
Day 2, Cycle 3 – Planned for 7/26/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
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
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 25 of 67
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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
temozolomide (TEMODAR) cap 195 mg
195 mg (rounded from 196 mg = 100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Administer at least one (1) hours prior to irinotecan infusion.
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
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 Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 26 of 67
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
temozolomide (TEMODAR) cap 195 mg
195 mg (rounded from 196 mg = 100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Administer at least one (1) hours prior to irinotecan infusion.
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
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 Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 27 of 67
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
temozolomide (TEMODAR) cap 195 mg
195 mg (rounded from 196 mg = 100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Administer at least one (1) hours prior to irinotecan infusion.
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
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
DISEASE: Ewing Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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
temozolomide (TEMODAR) cap 195 mg
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 28 of 67
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

195 mg (rounded from 196 mg = 100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Administer at least one (1) hours prior to irinotecan infusion.
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 3 – Planned for 8/1/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+3 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+3 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets and Hemoglobin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL or
Hemoglobin less than 8 g/dL.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 29 of 67
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 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 9, Cycle 3 – Planned for 8/2/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 30 of 67
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 10, Cycle 3 – Planned for 8/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 31 of 67
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
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 11, Cycle 3 – Planned for 8/4/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
Follow-Up
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 32 of 67
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 12, Cycle 3 – Planned for 8/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15 - Lab Only, Cycle 3 – Planned for 8/6/2017
Treatment Plan Information
Treatment Plan Summary
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 33 of 67
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

DISEASE: Ewing Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+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.
Cycle 4 – 8/15/2017 through 9/4/2017 (21 days), Planned
Day 1, Cycle 4 – Planned for 8/15/2017
Treatment Plan Information
Reference Information (1)
EWING SARCOMA: Wagner LM, et al Pediatr Blood Cancer 2007;48(2):132-9.
Reference Information (2)
EWING SARCOMA: Casey DA, et al. Pediatr Blood Cancer 2009;53(6):1029-34.
Treatment Plan Summary
DISEASE: Ewing Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+10 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+10 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+10 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+10 Approximate, Expires-S+365, Routine
BUN
Expected-S+10 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+10 Approximate, Expires-S+365, Routine
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 34 of 67
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

BILIRUBIN, TOTAL
Expected-S+10 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+10 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+10 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+10 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets and Hemoglobin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL or
Hemoglobin less than 8 g/dL.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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
temozolomide (TEMODAR) cap 195 mg
195 mg (rounded from 196 mg = 100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Administer at least one (1) hours prior to irinotecan infusion.
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 35 of 67
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: temozolomide and irinotecan for 180 minutes.
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: temozolomide and irinotecan for 180 minutes.
DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: temozolomide and irinotecan for 180 minutes.
DAY 5 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: temozolomide and irinotecan for 180 minutes.
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: irinotecan for 150 minutes.
DAY 9 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: irinotecan for 150 minutes.
DAY 10 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: irinotecan for 150 minutes.
DAY 11 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: irinotecan for 150 minutes.
DAY 12 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: irinotecan for 150 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Electrolytes,
Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT:
temozolomide and irinotecan for 180 minutes.
Day 2, Cycle 4 – Planned for 8/16/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
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
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 36 of 67
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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
temozolomide (TEMODAR) cap 195 mg
195 mg (rounded from 196 mg = 100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Administer at least one (1) hours prior to irinotecan infusion.
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 4 – Planned for 8/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 37 of 67
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
temozolomide (TEMODAR) cap 195 mg
195 mg (rounded from 196 mg = 100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Administer at least one (1) hours prior to irinotecan infusion.
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
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 Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 38 of 67
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
temozolomide (TEMODAR) cap 195 mg
195 mg (rounded from 196 mg = 100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Administer at least one (1) hours prior to irinotecan infusion.
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
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 Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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
temozolomide (TEMODAR) cap 195 mg
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 39 of 67
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

195 mg (rounded from 196 mg = 100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Administer at least one (1) hours prior to irinotecan infusion.
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 4 – Planned for 8/22/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+3 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+3 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets and Hemoglobin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL or
Hemoglobin less than 8 g/dL.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 40 of 67
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 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 9, Cycle 4 – Planned for 8/23/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 41 of 67
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 10, Cycle 4 – Planned for 8/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 42 of 67
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
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 11, Cycle 4 – Planned for 8/25/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
Follow-Up
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 43 of 67
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 12, Cycle 4 – Planned for 8/26/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15 - Lab Only, Cycle 4 – Planned for 8/27/2017
Treatment Plan Information
Treatment Plan Summary
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 44 of 67
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

DISEASE: Ewing Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+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.
Cycle 5 – 9/5/2017 through 9/25/2017 (21 days), Planned
Day 1, Cycle 5 – Planned for 9/5/2017
Treatment Plan Information
Reference Information (1)
EWING SARCOMA: Wagner LM, et al Pediatr Blood Cancer 2007;48(2):132-9.
Reference Information (2)
EWING SARCOMA: Casey DA, et al. Pediatr Blood Cancer 2009;53(6):1029-34.
Treatment Plan Summary
DISEASE: Ewing Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+10 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+10 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+10 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+10 Approximate, Expires-S+365, Routine
BUN
Expected-S+10 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+10 Approximate, Expires-S+365, Routine
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 45 of 67
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

BILIRUBIN, TOTAL
Expected-S+10 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+10 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+10 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+10 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets and Hemoglobin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL or
Hemoglobin less than 8 g/dL.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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
temozolomide (TEMODAR) cap 195 mg
195 mg (rounded from 196 mg = 100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Administer at least one (1) hours prior to irinotecan infusion.
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 46 of 67
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: temozolomide and irinotecan for 180 minutes.
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: temozolomide and irinotecan for 180 minutes.
DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: temozolomide and irinotecan for 180 minutes.
DAY 5 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: temozolomide and irinotecan for 180 minutes.
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: irinotecan for 150 minutes.
DAY 9 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: irinotecan for 150 minutes.
DAY 10 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: irinotecan for 150 minutes.
DAY 11 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: irinotecan for 150 minutes.
DAY 12 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: irinotecan for 150 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Electrolytes,
Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT:
temozolomide and irinotecan for 180 minutes.
Day 2, Cycle 5 – Planned for 9/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
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
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 47 of 67
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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
temozolomide (TEMODAR) cap 195 mg
195 mg (rounded from 196 mg = 100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Administer at least one (1) hours prior to irinotecan infusion.
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
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 Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 48 of 67
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
temozolomide (TEMODAR) cap 195 mg
195 mg (rounded from 196 mg = 100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Administer at least one (1) hours prior to irinotecan infusion.
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
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 Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 49 of 67
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
temozolomide (TEMODAR) cap 195 mg
195 mg (rounded from 196 mg = 100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Administer at least one (1) hours prior to irinotecan infusion.
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
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 Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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
temozolomide (TEMODAR) cap 195 mg
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 50 of 67
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

195 mg (rounded from 196 mg = 100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Administer at least one (1) hours prior to irinotecan infusion.
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 5 – Planned for 9/12/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+3 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+3 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets and Hemoglobin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL or
Hemoglobin less than 8 g/dL.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 51 of 67
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 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 9, Cycle 5 – Planned for 9/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 52 of 67
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 10, Cycle 5 – Planned for 9/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 53 of 67
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
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 11, Cycle 5 – Planned for 9/15/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
Follow-Up
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 54 of 67
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 12, Cycle 5 – Planned for 9/16/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15 - Lab Only, Cycle 5 – Planned for 9/17/2017
Treatment Plan Information
Treatment Plan Summary
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 55 of 67
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

DISEASE: Ewing Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+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.
Cycle 6 – 9/26/2017 through 10/16/2017 (21 days), Planned
Day 1, Cycle 6 – Planned for 9/26/2017
Treatment Plan Information
Reference Information (1)
EWING SARCOMA: Wagner LM, et al Pediatr Blood Cancer 2007;48(2):132-9.
Reference Information (2)
EWING SARCOMA: Casey DA, et al. Pediatr Blood Cancer 2009;53(6):1029-34.
Treatment Plan Summary
DISEASE: Ewing Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+10 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+10 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+10 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+10 Approximate, Expires-S+365, Routine
BUN
Expected-S+10 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+10 Approximate, Expires-S+365, Routine
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 56 of 67
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

BILIRUBIN, TOTAL
Expected-S+10 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+10 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+10 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+10 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets and Hemoglobin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL or
Hemoglobin less than 8 g/dL.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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
temozolomide (TEMODAR) cap 195 mg
195 mg (rounded from 196 mg = 100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Administer at least one (1) hours prior to irinotecan infusion.
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 57 of 67
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: temozolomide and irinotecan for 180 minutes.
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: temozolomide and irinotecan for 180 minutes.
DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: temozolomide and irinotecan for 180 minutes.
DAY 5 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: temozolomide and irinotecan for 180 minutes.
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: irinotecan for 150 minutes.
DAY 9 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: irinotecan for 150 minutes.
DAY 10 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: irinotecan for 150 minutes.
DAY 11 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: irinotecan for 150 minutes.
DAY 12 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: irinotecan for 150 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Electrolytes,
Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT:
temozolomide and irinotecan for 180 minutes.
Day 2, Cycle 6 – Planned for 9/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
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
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 58 of 67
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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
temozolomide (TEMODAR) cap 195 mg
195 mg (rounded from 196 mg = 100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Administer at least one (1) hours prior to irinotecan infusion.
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
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 Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 59 of 67
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
temozolomide (TEMODAR) cap 195 mg
195 mg (rounded from 196 mg = 100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Administer at least one (1) hours prior to irinotecan infusion.
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
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
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 60 of 67
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
temozolomide (TEMODAR) cap 195 mg
195 mg (rounded from 196 mg = 100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Administer at least one (1) hours prior to irinotecan infusion.
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
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 Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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
temozolomide (TEMODAR) cap 195 mg
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 61 of 67
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

195 mg (rounded from 196 mg = 100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Administer at least one (1) hours prior to irinotecan infusion.
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 6 – Planned for 10/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+3 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+3 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets and Hemoglobin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL or
Hemoglobin less than 8 g/dL.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 62 of 67
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 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 9, Cycle 6 – Planned for 10/4/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 63 of 67
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 10, Cycle 6 – Planned for 10/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 64 of 67
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
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 11, Cycle 6 – Planned for 10/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
Follow-Up
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 65 of 67
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 12, Cycle 6 – Planned for 10/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or weakness).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, EVERY 15 MINUTES PRN, 2 doses Starting when released, to manage cholinergic side effects, Administer
over 1 Minutes
May repeat x1 dose.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15 - Lab Only, Cycle 6 – Planned for 10/8/2017
Treatment Plan Information
Treatment Plan Summary
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 66 of 67
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

DISEASE: Ewing Sarcoma (Advanced); THERAPY: irinotecan 10 to 20 mg/m2 IV Day 1 through 5 and Day 8 through 12,
temozolomide 100 mg/m2 by mouth Day 1 through 5; CYCLE LENGTH: 21 Days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+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.
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Zztestonc,Jeff J [2507481]
6/13/2017 3:58:34 PM Page 67 of 67
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org