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201706165

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UWHC,UWMF,

Tools,

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

CSC Sarcoma VTC Alternating With VAC VER 5-1-17 (HL 974)

CSC Sarcoma VTC Alternating With VAC VER 5-1-17 (HL 974) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Sarcoma


CSC SARCOMA VTC ALTERNATING W VAC VER 5-1-17 (HL 974) – 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: Rhabdomyosarcoma (Advanced); THERAPY: vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1; topotecan 0.75
mg/m2 IV Day 1 through 5; cyclophosphamide 250 mg/m2 IV Day 1 through 5; mesna 250 mg/m2 IV/by mouth prior to
cyclophosphamide (optional) Day 1 through 5, alternating cycles with vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1;
DACTINOmycin 1.5 mg/m2 (max dose = 2.5 mg) IV Day 1, cyclophosphamide 2200 mg/m2 IV Day 1; mesna 450 mg/m2 IV prior to
cyclophosphamide and 450 mg/m2 by mouth every 3 hours after start of cyclophosphamide for a total of four doses Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 alternating cycles or until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S Approximate, Expires-S+365, Routine
BUN
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S Approximate, Expires-S+365, Routine
Take Home Medications
sulfamethoxazole-trimethoprim (BACTRIM DS) 800-160 MG per tab
Take 1 tab by mouth 2 times daily., 1 tab, Disp-42 tab, R-7, 2 X DAILY starting S
Take for PCP prophylaxis. Contact MD for alternate if Sulfa allergy.
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 orally twice daily on Day 6 and 7 then 1 tab every 8h as needed for nausea, Disp-30 tab, R-5, starting S, Local Printer
Take Home Medications (delete all that do not apply)
TBO-filgrastim (GRANIX) 300 MCG/0.5ML soln prefilled syringe
Inject 300 mcg under skin one time daily in evening. Begin Day ***. Continue until ANC is greater than *** after nadir., 300 mcg,
Disp-10 Syringe, R-5, 1 X DAILY (PM) starting S, Local Printer
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
TBO-filgrastim (GRANIX) 480 MCG/0.8ML soln prefilled syringe
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Zztestonc,Jeff J [2507481]
6/13/2017 4:04:26 PM Page 1 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Inject 480 mcg under skin one time daily in evening. Begin Day ***. Continue until ANC is greater than *** after nadir., 480 mcg,
Disp-10 Syringe, R-5, 1 X DAILY (PM) starting S, Local Printer
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
Cycle 1 - VTC – 6/13/2017 through 7/3/2017 (21 days), Planned
Day 1, Cycle 1 - VTC – Planned for 6/13/2017
Treatment Plan Information
Reference Information (1)
SARCOMA: Pappo AS, et al. J Clin Oncol 2001;19:213-9
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Advanced); THERAPY: vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1; topotecan 0.75
mg/m2 IV Day 1 through 5; cyclophosphamide 250 mg/m2 IV Day 1 through 5; mesna 250 mg/m2 IV/by mouth prior to
cyclophosphamide (optional) Day 1 through 5, alternating cycles with vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1;
DACTINOmycin 1.5 mg/m2 (max dose = 2.5 mg) IV Day 1, cyclophosphamide 2200 mg/m2 IV Day 1; mesna 450 mg/m2 IV prior to
cyclophosphamide and 450 mg/m2 by mouth every 3 hours after start of cyclophosphamide for a total of four doses Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 alternating cycles or until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than upper limits of normal.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
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Zztestonc,Jeff J [2507481]
6/13/2017 4:04:26 PM Page 2 of 38
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
vinCRIStine (ONCOVIN) 2.9 mg in sodium chloride 0.9 % 25 mL bag
2.9 mg (rounded from 2.94 mg = 1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3-5 Minutes
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
topotecan (HYCAMTIN) 1.47 mg in sodium chloride 0.9 % 100 mL bag
1.47 mg (0.75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
mesna (MESNEX) 490 mg in sodium chloride 0.9 % 50 mL bag
490 mg (250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer just prior to cyclophosphamide. May be be given orally at the physicians discretion.
Mesna dosing optional; delete if not needed
cyclophosphamide (CYTOXAN) 490 mg in sodium chloride 0.9 % 250 mL bag
490 mg (250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Mesna 250 mg/m2 OPTIONAL prior to cyclophosphamide.
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: topotecan and cyclophosphamide for 120 minutes.
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: topotecan and cyclophosphamide for 120 minutes.
DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: topotecan and cyclophosphamide for 120 minutes.
DAY 5 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: topotecan and cyclophosphamide for 120 minutes.
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Electrolytes, Glucose, BUN,
Creatinine, Total Bilirubin, AST, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: vinCRIStine, DACTINOmycin,
and cyclophosphamide for 150 minutes.
Day 2, Cycle 1 - VTC – Planned for 6/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Advanced); THERAPY: vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1; topotecan 0.75
mg/m2 IV Day 1 through 5; cyclophosphamide 250 mg/m2 IV Day 1 through 5; mesna 250 mg/m2 IV/by mouth prior to
cyclophosphamide (optional) Day 1 through 5, alternating cycles with vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1;
DACTINOmycin 1.5 mg/m2 (max dose = 2.5 mg) IV Day 1, cyclophosphamide 2200 mg/m2 IV Day 1; mesna 450 mg/m2 IV prior to
cyclophosphamide and 450 mg/m2 by mouth every 3 hours after start of cyclophosphamide for a total of four doses Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 alternating cycles or until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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Zztestonc,Jeff J [2507481]
6/13/2017 4:04:26 PM Page 3 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
topotecan (HYCAMTIN) 1.47 mg in sodium chloride 0.9 % 100 mL bag
1.47 mg (0.75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
mesna (MESNEX) 490 mg in sodium chloride 0.9 % 50 mL bag
490 mg (250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer just prior to cyclophosphamide. May be be given orally at the physicians discretion.
Mesna dosing optional; delete if not needed
cyclophosphamide (CYTOXAN) 490 mg in sodium chloride 0.9 % 250 mL bag
490 mg (250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Mesna 250 mg/m2 OPTIONAL prior to cyclophosphamide.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 1 - VTC – Planned for 6/15/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Advanced); THERAPY: vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1; topotecan 0.75
mg/m2 IV Day 1 through 5; cyclophosphamide 250 mg/m2 IV Day 1 through 5; mesna 250 mg/m2 IV/by mouth prior to
cyclophosphamide (optional) Day 1 through 5, alternating cycles with vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1;
DACTINOmycin 1.5 mg/m2 (max dose = 2.5 mg) IV Day 1, cyclophosphamide 2200 mg/m2 IV Day 1; mesna 450 mg/m2 IV prior to
cyclophosphamide and 450 mg/m2 by mouth every 3 hours after start of cyclophosphamide for a total of four doses Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 alternating cycles or until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
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Zztestonc,Jeff J [2507481]
6/13/2017 4:04:26 PM Page 4 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
topotecan (HYCAMTIN) 1.47 mg in sodium chloride 0.9 % 100 mL bag
1.47 mg (0.75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
mesna (MESNEX) 490 mg in sodium chloride 0.9 % 50 mL bag
490 mg (250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer just prior to cyclophosphamide. May be be given orally at the physicians discretion.
Mesna dosing optional; delete if not needed
cyclophosphamide (CYTOXAN) 490 mg in sodium chloride 0.9 % 250 mL bag
490 mg (250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Mesna 250 mg/m2 OPTIONAL prior to cyclophosphamide.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 4, Cycle 1 - VTC – Planned for 6/16/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Advanced); THERAPY: vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1; topotecan 0.75
mg/m2 IV Day 1 through 5; cyclophosphamide 250 mg/m2 IV Day 1 through 5; mesna 250 mg/m2 IV/by mouth prior to
cyclophosphamide (optional) Day 1 through 5, alternating cycles with vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1;
DACTINOmycin 1.5 mg/m2 (max dose = 2.5 mg) IV Day 1, cyclophosphamide 2200 mg/m2 IV Day 1; mesna 450 mg/m2 IV prior to
cyclophosphamide and 450 mg/m2 by mouth every 3 hours after start of cyclophosphamide for a total of four doses Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 alternating cycles or until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
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Zztestonc,Jeff J [2507481]
6/13/2017 4:04:26 PM Page 5 of 38
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 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
topotecan (HYCAMTIN) 1.47 mg in sodium chloride 0.9 % 100 mL bag
1.47 mg (0.75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
mesna (MESNEX) 490 mg in sodium chloride 0.9 % 50 mL bag
490 mg (250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer just prior to cyclophosphamide. May be be given orally at the physicians discretion.
Mesna dosing optional; delete if not needed
cyclophosphamide (CYTOXAN) 490 mg in sodium chloride 0.9 % 250 mL bag
490 mg (250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Mesna 250 mg/m2 OPTIONAL prior to cyclophosphamide.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 1 - VTC – Planned for 6/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Advanced); THERAPY: vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1; topotecan 0.75
mg/m2 IV Day 1 through 5; cyclophosphamide 250 mg/m2 IV Day 1 through 5; mesna 250 mg/m2 IV/by mouth prior to
cyclophosphamide (optional) Day 1 through 5, alternating cycles with vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1;
DACTINOmycin 1.5 mg/m2 (max dose = 2.5 mg) IV Day 1, cyclophosphamide 2200 mg/m2 IV Day 1; mesna 450 mg/m2 IV prior to
cyclophosphamide and 450 mg/m2 by mouth every 3 hours after start of cyclophosphamide for a total of four doses Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 alternating cycles or until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
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Zztestonc,Jeff J [2507481]
6/13/2017 4:04:26 PM Page 6 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
topotecan (HYCAMTIN) 1.47 mg in sodium chloride 0.9 % 100 mL bag
1.47 mg (0.75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
mesna (MESNEX) 490 mg in sodium chloride 0.9 % 50 mL bag
490 mg (250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer just prior to cyclophosphamide. May be be given orally at the physicians discretion.
Mesna dosing optional; delete if not needed
cyclophosphamide (CYTOXAN) 490 mg in sodium chloride 0.9 % 250 mL bag
490 mg (250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Mesna 250 mg/m2 OPTIONAL prior to cyclophosphamide.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 10, Cycle 1 - VTC – Planned for 6/22/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Advanced); THERAPY: vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1; topotecan 0.75
mg/m2 IV Day 1 through 5; cyclophosphamide 250 mg/m2 IV Day 1 through 5; mesna 250 mg/m2 IV/by mouth prior to
cyclophosphamide (optional) Day 1 through 5, alternating cycles with vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1;
DACTINOmycin 1.5 mg/m2 (max dose = 2.5 mg) IV Day 1, cyclophosphamide 2200 mg/m2 IV Day 1; mesna 450 mg/m2 IV prior to
cyclophosphamide and 450 mg/m2 by mouth every 3 hours after start of cyclophosphamide for a total of four doses Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 alternating cycles or until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+5 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+5 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 - VAC – 7/4/2017 through 7/24/2017 (21 days), Planned
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Zztestonc,Jeff J [2507481]
6/13/2017 4:04:26 PM Page 7 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Day 1, Cycle 2 - VAC – Planned for 7/4/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Advanced); THERAPY: vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1; topotecan 0.75
mg/m2 IV Day 1 through 5; cyclophosphamide 250 mg/m2 IV Day 1 through 5; mesna 250 mg/m2 IV/by mouth prior to
cyclophosphamide (optional) Day 1 through 5, alternating cycles with vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1;
DACTINOmycin 1.5 mg/m2 (max dose = 2.5 mg) IV Day 1, cyclophosphamide 2200 mg/m2 IV Day 1; mesna 450 mg/m2 IV prior to
cyclophosphamide and 450 mg/m2 by mouth every 3 hours after start of cyclophosphamide for a total of four doses Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 alternating cycles or until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+17 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+17 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+17 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+17 Approximate, Expires-S+365, Routine
BUN
Expected-S+17 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+17 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+17 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+17 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+17 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than upper limits of normal.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
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Zztestonc,Jeff J [2507481]
6/13/2017 4:04:26 PM Page 8 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
vinCRIStine (ONCOVIN) 2.9 mg in sodium chloride 0.9 % 25 mL bag
2.9 mg (rounded from 2.94 mg = 1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3-5 Minutes
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
DACTINOmycin (COSMOGEN) injection 2,940 mcg
2,940 mcg (1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
IV push over 1-5 minutes into running IV. Max dose = 2500 mcg.
mesna (MESNEX) 882 mg in sodium chloride 0.9 % 50 mL bag
882 mg (450 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give prior to start of cyclophosphamide.
cyclophosphamide (CYTOXAN) 4,312 mg bag
4,312 mg (2,200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): mesna oral at 3 hours and 6 hours and 9 hours
after the start of cyclophosphamide.
Take Home Medications
mesna (MESNEX) 400 MG tab
Take 2 tabs by mouth 3 times daily. Take 3h, 6h and 9h after start of cyclophosphamide., 800 mg (rounded from 882 mg = 450
mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-5, 3 X DAILY starting S
aprepitant (EMEND) 80 MG cap
Take 1 cap by mouth one time daily. Take for 2 days following treatment., 80 mg, Disp-2 cap, R-13, 1 X DAILY starting S
dexamethasone (DECADRON) 4 MG tab
Take 2 tabs by mouth one time daily. Take for 3 days following chemotherapy, 8 mg, Disp-42 tab, R-1, 1 X DAILY starting S
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2,500 mcg.
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Zztestonc,Jeff J [2507481]
6/13/2017 4:04:26 PM Page 9 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Verify Day 22 (Day 1 of next cycle) appointments have been scheduled: RETURN TO CLINIC for appointment with provider; LABS:
CBC, ANC (DIFF if to be done locally), Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, Alkaline Phosphatase;
CHEMOTHERAPY ROOM APPOINTMENT: vinCRIStine, topotecan, and cyclophosphamide for 150 minutes.
Lab Only - Day 8, Cycle 2 - VAC – Planned for 7/11/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Advanced); THERAPY: vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1; topotecan 0.75
mg/m2 IV Day 1 through 5; cyclophosphamide 250 mg/m2 IV Day 1 through 5; mesna 250 mg/m2 IV/by mouth prior to
cyclophosphamide (optional) Day 1 through 5, alternating cycles with vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1;
DACTINOmycin 1.5 mg/m2 (max dose = 2.5 mg) IV Day 1, cyclophosphamide 2200 mg/m2 IV Day 1; mesna 450 mg/m2 IV prior to
cyclophosphamide and 450 mg/m2 by mouth every 3 hours after start of cyclophosphamide for a total of four doses Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 alternating cycles or until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 2 - VAC – Planned for 7/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Advanced); THERAPY: vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1; topotecan 0.75
mg/m2 IV Day 1 through 5; cyclophosphamide 250 mg/m2 IV Day 1 through 5; mesna 250 mg/m2 IV/by mouth prior to
cyclophosphamide (optional) Day 1 through 5, alternating cycles with vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1;
DACTINOmycin 1.5 mg/m2 (max dose = 2.5 mg) IV Day 1, cyclophosphamide 2200 mg/m2 IV Day 1; mesna 450 mg/m2 IV prior to
cyclophosphamide and 450 mg/m2 by mouth every 3 hours after start of cyclophosphamide for a total of four doses Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 alternating cycles or until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 - VTC – 7/25/2017 through 8/14/2017 (21 days), Planned
Day 1, Cycle 3 - VTC – Planned for 7/25/2017
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Zztestonc,Jeff J [2507481]
6/13/2017 4:04:26 PM Page 10 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Advanced); THERAPY: vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1; topotecan 0.75
mg/m2 IV Day 1 through 5; cyclophosphamide 250 mg/m2 IV Day 1 through 5; mesna 250 mg/m2 IV/by mouth prior to
cyclophosphamide (optional) Day 1 through 5, alternating cycles with vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1;
DACTINOmycin 1.5 mg/m2 (max dose = 2.5 mg) IV Day 1, cyclophosphamide 2200 mg/m2 IV Day 1; mesna 450 mg/m2 IV prior to
cyclophosphamide and 450 mg/m2 by mouth every 3 hours after start of cyclophosphamide for a total of four doses Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 alternating cycles or until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S Approximate, Expires-S+365, Routine
BUN
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than upper limits of normal.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
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Zztestonc,Jeff J [2507481]
6/13/2017 4:04:26 PM Page 11 of 38
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 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
vinCRIStine (ONCOVIN) 2.9 mg in sodium chloride 0.9 % 25 mL bag
2.9 mg (rounded from 2.94 mg = 1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3-5 Minutes
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
topotecan (HYCAMTIN) 1.47 mg in sodium chloride 0.9 % 100 mL bag
1.47 mg (0.75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
mesna (MESNEX) 490 mg in sodium chloride 0.9 % 50 mL bag
490 mg (250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer just prior to cyclophosphamide. May be be given orally at the physicians discretion.
Mesna dosing optional; delete if not needed
cyclophosphamide (CYTOXAN) 490 mg in sodium chloride 0.9 % 250 mL bag
490 mg (250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Mesna 250 mg/m2 OPTIONAL prior to cyclophosphamide.
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: topotecan and cyclophosphamide for 120 minutes.
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: topotecan and cyclophosphamide for 120 minutes.
DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: topotecan and cyclophosphamide for 120 minutes.
DAY 5 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: topotecan and cyclophosphamide for 120 minutes.
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Electrolytes, Glucose, BUN,
Creatinine, Total Bilirubin, AST, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: vinCRIStine, DACTINOmycin,
and cyclophosphamide for 150 minutes.
Day 2, Cycle 3 - VTC – Planned for 7/26/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Advanced); THERAPY: vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1; topotecan 0.75
mg/m2 IV Day 1 through 5; cyclophosphamide 250 mg/m2 IV Day 1 through 5; mesna 250 mg/m2 IV/by mouth prior to
cyclophosphamide (optional) Day 1 through 5, alternating cycles with vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1;
DACTINOmycin 1.5 mg/m2 (max dose = 2.5 mg) IV Day 1, cyclophosphamide 2200 mg/m2 IV Day 1; mesna 450 mg/m2 IV prior to
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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Zztestonc,Jeff J [2507481]
6/13/2017 4:04:26 PM Page 12 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

cyclophosphamide and 450 mg/m2 by mouth every 3 hours after start of cyclophosphamide for a total of four doses Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 alternating cycles or until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
topotecan (HYCAMTIN) 1.47 mg in sodium chloride 0.9 % 100 mL bag
1.47 mg (0.75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
mesna (MESNEX) 490 mg in sodium chloride 0.9 % 50 mL bag
490 mg (250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer just prior to cyclophosphamide. May be be given orally at the physicians discretion.
Mesna dosing optional; delete if not needed
cyclophosphamide (CYTOXAN) 490 mg in sodium chloride 0.9 % 250 mL bag
490 mg (250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Mesna 250 mg/m2 OPTIONAL prior to cyclophosphamide.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 3 - VTC – Planned for 7/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Advanced); THERAPY: vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1; topotecan 0.75
mg/m2 IV Day 1 through 5; cyclophosphamide 250 mg/m2 IV Day 1 through 5; mesna 250 mg/m2 IV/by mouth prior to
cyclophosphamide (optional) Day 1 through 5, alternating cycles with vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1;
DACTINOmycin 1.5 mg/m2 (max dose = 2.5 mg) IV Day 1, cyclophosphamide 2200 mg/m2 IV Day 1; mesna 450 mg/m2 IV prior to
cyclophosphamide and 450 mg/m2 by mouth every 3 hours after start of cyclophosphamide for a total of four doses Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 alternating cycles or until disease progression.
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Zztestonc,Jeff J [2507481]
6/13/2017 4:04:26 PM Page 13 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
topotecan (HYCAMTIN) 1.47 mg in sodium chloride 0.9 % 100 mL bag
1.47 mg (0.75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
mesna (MESNEX) 490 mg in sodium chloride 0.9 % 50 mL bag
490 mg (250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer just prior to cyclophosphamide. May be be given orally at the physicians discretion.
Mesna dosing optional; delete if not needed
cyclophosphamide (CYTOXAN) 490 mg in sodium chloride 0.9 % 250 mL bag
490 mg (250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Mesna 250 mg/m2 OPTIONAL prior to cyclophosphamide.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 4, Cycle 3 - VTC – Planned for 7/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Advanced); THERAPY: vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1; topotecan 0.75
mg/m2 IV Day 1 through 5; cyclophosphamide 250 mg/m2 IV Day 1 through 5; mesna 250 mg/m2 IV/by mouth prior to
cyclophosphamide (optional) Day 1 through 5, alternating cycles with vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1;
DACTINOmycin 1.5 mg/m2 (max dose = 2.5 mg) IV Day 1, cyclophosphamide 2200 mg/m2 IV Day 1; mesna 450 mg/m2 IV prior to
cyclophosphamide and 450 mg/m2 by mouth every 3 hours after start of cyclophosphamide for a total of four doses Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 alternating cycles or until disease progression.
IV Access
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Zztestonc,Jeff J [2507481]
6/13/2017 4:04:26 PM Page 14 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
topotecan (HYCAMTIN) 1.47 mg in sodium chloride 0.9 % 100 mL bag
1.47 mg (0.75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
mesna (MESNEX) 490 mg in sodium chloride 0.9 % 50 mL bag
490 mg (250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer just prior to cyclophosphamide. May be be given orally at the physicians discretion.
Mesna dosing optional; delete if not needed
cyclophosphamide (CYTOXAN) 490 mg in sodium chloride 0.9 % 250 mL bag
490 mg (250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Mesna 250 mg/m2 OPTIONAL prior to cyclophosphamide.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 3 - VTC – Planned for 7/29/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Advanced); THERAPY: vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1; topotecan 0.75
mg/m2 IV Day 1 through 5; cyclophosphamide 250 mg/m2 IV Day 1 through 5; mesna 250 mg/m2 IV/by mouth prior to
cyclophosphamide (optional) Day 1 through 5, alternating cycles with vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1;
DACTINOmycin 1.5 mg/m2 (max dose = 2.5 mg) IV Day 1, cyclophosphamide 2200 mg/m2 IV Day 1; mesna 450 mg/m2 IV prior to
cyclophosphamide and 450 mg/m2 by mouth every 3 hours after start of cyclophosphamide for a total of four doses Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 alternating cycles or until disease progression.
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Jeff J [2507481]
6/13/2017 4:04:26 PM Page 15 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
topotecan (HYCAMTIN) 1.47 mg in sodium chloride 0.9 % 100 mL bag
1.47 mg (0.75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
mesna (MESNEX) 490 mg in sodium chloride 0.9 % 50 mL bag
490 mg (250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer just prior to cyclophosphamide. May be be given orally at the physicians discretion.
Mesna dosing optional; delete if not needed
cyclophosphamide (CYTOXAN) 490 mg in sodium chloride 0.9 % 250 mL bag
490 mg (250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Mesna 250 mg/m2 OPTIONAL prior to cyclophosphamide.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 10, Cycle 3 - VTC – Planned for 8/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Advanced); THERAPY: vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1; topotecan 0.75
mg/m2 IV Day 1 through 5; cyclophosphamide 250 mg/m2 IV Day 1 through 5; mesna 250 mg/m2 IV/by mouth prior to
cyclophosphamide (optional) Day 1 through 5, alternating cycles with vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1;
DACTINOmycin 1.5 mg/m2 (max dose = 2.5 mg) IV Day 1, cyclophosphamide 2200 mg/m2 IV Day 1; mesna 450 mg/m2 IV prior to
cyclophosphamide and 450 mg/m2 by mouth every 3 hours after start of cyclophosphamide for a total of four doses Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 alternating cycles or until disease progression.
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Jeff J [2507481]
6/13/2017 4:04:26 PM Page 16 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+5 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+5 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 - VAC – 8/15/2017 through 9/4/2017 (21 days), Planned
Day 1, Cycle 4 - VAC – Planned for 8/15/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Advanced); THERAPY: vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1; topotecan 0.75
mg/m2 IV Day 1 through 5; cyclophosphamide 250 mg/m2 IV Day 1 through 5; mesna 250 mg/m2 IV/by mouth prior to
cyclophosphamide (optional) Day 1 through 5, alternating cycles with vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1;
DACTINOmycin 1.5 mg/m2 (max dose = 2.5 mg) IV Day 1, cyclophosphamide 2200 mg/m2 IV Day 1; mesna 450 mg/m2 IV prior to
cyclophosphamide and 450 mg/m2 by mouth every 3 hours after start of cyclophosphamide for a total of four doses Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 alternating cycles or until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+17 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+17 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+17 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+17 Approximate, Expires-S+365, Routine
BUN
Expected-S+17 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+17 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+17 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+17 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+17 Approximate, Expires-S+365, Routine
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Zztestonc,Jeff J [2507481]
6/13/2017 4:04:26 PM Page 17 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than upper limits of normal.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
vinCRIStine (ONCOVIN) 2.9 mg in sodium chloride 0.9 % 25 mL bag
2.9 mg (rounded from 2.94 mg = 1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3-5 Minutes
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
DACTINOmycin (COSMOGEN) injection 2,940 mcg
2,940 mcg (1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
IV push over 1-5 minutes into running IV. Max dose = 2500 mcg.
mesna (MESNEX) 882 mg in sodium chloride 0.9 % 50 mL bag
882 mg (450 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give prior to start of cyclophosphamide.
cyclophosphamide (CYTOXAN) 4,312 mg bag
4,312 mg (2,200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): mesna oral at 3 hours and 6 hours and 9 hours
after the start of cyclophosphamide.
Take Home Medications
mesna (MESNEX) 400 MG tab
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2,500 mcg.
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Zztestonc,Jeff J [2507481]
6/13/2017 4:04:26 PM Page 18 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Take 2 tabs by mouth 3 times daily. Take 3h, 6h and 9h after start of cyclophosphamide., 800 mg (rounded from
882 mg = 450 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-5, 3 X DAILY starting S
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
Verify Day 22 (Day 1 of next cycle) appointments have been scheduled: RETURN TO CLINIC for appointment with provider; LABS:
CBC, ANC (DIFF if to be done locally), Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, Alkaline Phosphatase;
CHEMOTHERAPY ROOM APPOINTMENT: vinCRIStine, topotecan, and cyclophosphamide for 150 minutes.
Lab Only - Day 8, Cycle 4 - VAC – Planned for 8/22/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Advanced); THERAPY: vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1; topotecan 0.75
mg/m2 IV Day 1 through 5; cyclophosphamide 250 mg/m2 IV Day 1 through 5; mesna 250 mg/m2 IV/by mouth prior to
cyclophosphamide (optional) Day 1 through 5, alternating cycles with vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1;
DACTINOmycin 1.5 mg/m2 (max dose = 2.5 mg) IV Day 1, cyclophosphamide 2200 mg/m2 IV Day 1; mesna 450 mg/m2 IV prior to
cyclophosphamide and 450 mg/m2 by mouth every 3 hours after start of cyclophosphamide for a total of four doses Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 alternating cycles or until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 4 - VAC – Planned for 8/29/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Advanced); THERAPY: vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1; topotecan 0.75
mg/m2 IV Day 1 through 5; cyclophosphamide 250 mg/m2 IV Day 1 through 5; mesna 250 mg/m2 IV/by mouth prior to
cyclophosphamide (optional) Day 1 through 5, alternating cycles with vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1;
DACTINOmycin 1.5 mg/m2 (max dose = 2.5 mg) IV Day 1, cyclophosphamide 2200 mg/m2 IV Day 1; mesna 450 mg/m2 IV prior to
cyclophosphamide and 450 mg/m2 by mouth every 3 hours after start of cyclophosphamide for a total of four doses Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 alternating cycles or until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
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Zztestonc,Jeff J [2507481]
6/13/2017 4:04:26 PM Page 19 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Expected-S+7 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 - VTC – 9/5/2017 through 9/25/2017 (21 days), Planned
Day 1, Cycle 5 - VTC – Planned for 9/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Advanced); THERAPY: vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1; topotecan 0.75
mg/m2 IV Day 1 through 5; cyclophosphamide 250 mg/m2 IV Day 1 through 5; mesna 250 mg/m2 IV/by mouth prior to
cyclophosphamide (optional) Day 1 through 5, alternating cycles with vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1;
DACTINOmycin 1.5 mg/m2 (max dose = 2.5 mg) IV Day 1, cyclophosphamide 2200 mg/m2 IV Day 1; mesna 450 mg/m2 IV prior to
cyclophosphamide and 450 mg/m2 by mouth every 3 hours after start of cyclophosphamide for a total of four doses Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 alternating cycles or until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S Approximate, Expires-S+365, Routine
BUN
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than upper limits of normal.
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Zztestonc,Jeff J [2507481]
6/13/2017 4:04:26 PM Page 20 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
vinCRIStine (ONCOVIN) 2.9 mg in sodium chloride 0.9 % 25 mL bag
2.9 mg (rounded from 2.94 mg = 1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3-5 Minutes
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
topotecan (HYCAMTIN) 1.47 mg in sodium chloride 0.9 % 100 mL bag
1.47 mg (0.75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
mesna (MESNEX) 490 mg in sodium chloride 0.9 % 50 mL bag
490 mg (250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer just prior to cyclophosphamide. May be be given orally at the physicians discretion.
Mesna dosing optional; delete if not needed
cyclophosphamide (CYTOXAN) 490 mg in sodium chloride 0.9 % 250 mL bag
490 mg (250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Mesna 250 mg/m2 OPTIONAL prior to cyclophosphamide.
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: topotecan and cyclophosphamide for 120 minutes.
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: topotecan and cyclophosphamide for 120 minutes.
DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: topotecan and cyclophosphamide for 120 minutes.
DAY 5 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: topotecan and cyclophosphamide for 120 minutes.
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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Zztestonc,Jeff J [2507481]
6/13/2017 4:04:26 PM Page 21 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Electrolytes, Glucose, BUN,
Creatinine, Total Bilirubin, AST, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: vinCRIStine, DACTINOmycin,
and cyclophosphamide for 150 minutes.
Day 2, Cycle 5 - VTC – Planned for 9/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Advanced); THERAPY: vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1; topotecan 0.75
mg/m2 IV Day 1 through 5; cyclophosphamide 250 mg/m2 IV Day 1 through 5; mesna 250 mg/m2 IV/by mouth prior to
cyclophosphamide (optional) Day 1 through 5, alternating cycles with vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1;
DACTINOmycin 1.5 mg/m2 (max dose = 2.5 mg) IV Day 1, cyclophosphamide 2200 mg/m2 IV Day 1; mesna 450 mg/m2 IV prior to
cyclophosphamide and 450 mg/m2 by mouth every 3 hours after start of cyclophosphamide for a total of four doses Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 alternating cycles or until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
topotecan (HYCAMTIN) 1.47 mg in sodium chloride 0.9 % 100 mL bag
1.47 mg (0.75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
mesna (MESNEX) 490 mg in sodium chloride 0.9 % 50 mL bag
490 mg (250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer just prior to cyclophosphamide. May be be given orally at the physicians discretion.
Mesna dosing optional; delete if not needed
cyclophosphamide (CYTOXAN) 490 mg in sodium chloride 0.9 % 250 mL bag
490 mg (250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Mesna 250 mg/m2 OPTIONAL prior to cyclophosphamide.
Follow-Up
VERIFY APPOINTMENTS
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Zztestonc,Jeff J [2507481]
6/13/2017 4:04:26 PM Page 22 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 5 - VTC – Planned for 9/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Advanced); THERAPY: vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1; topotecan 0.75
mg/m2 IV Day 1 through 5; cyclophosphamide 250 mg/m2 IV Day 1 through 5; mesna 250 mg/m2 IV/by mouth prior to
cyclophosphamide (optional) Day 1 through 5, alternating cycles with vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1;
DACTINOmycin 1.5 mg/m2 (max dose = 2.5 mg) IV Day 1, cyclophosphamide 2200 mg/m2 IV Day 1; mesna 450 mg/m2 IV prior to
cyclophosphamide and 450 mg/m2 by mouth every 3 hours after start of cyclophosphamide for a total of four doses Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 alternating cycles or until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
topotecan (HYCAMTIN) 1.47 mg in sodium chloride 0.9 % 100 mL bag
1.47 mg (0.75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
mesna (MESNEX) 490 mg in sodium chloride 0.9 % 50 mL bag
490 mg (250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer just prior to cyclophosphamide. May be be given orally at the physicians discretion.
Mesna dosing optional; delete if not needed
cyclophosphamide (CYTOXAN) 490 mg in sodium chloride 0.9 % 250 mL bag
490 mg (250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Mesna 250 mg/m2 OPTIONAL prior to cyclophosphamide.
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 4:04:26 PM Page 23 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Day 4, Cycle 5 - VTC – Planned for 9/8/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Advanced); THERAPY: vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1; topotecan 0.75
mg/m2 IV Day 1 through 5; cyclophosphamide 250 mg/m2 IV Day 1 through 5; mesna 250 mg/m2 IV/by mouth prior to
cyclophosphamide (optional) Day 1 through 5, alternating cycles with vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1;
DACTINOmycin 1.5 mg/m2 (max dose = 2.5 mg) IV Day 1, cyclophosphamide 2200 mg/m2 IV Day 1; mesna 450 mg/m2 IV prior to
cyclophosphamide and 450 mg/m2 by mouth every 3 hours after start of cyclophosphamide for a total of four doses Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 alternating cycles or until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
topotecan (HYCAMTIN) 1.47 mg in sodium chloride 0.9 % 100 mL bag
1.47 mg (0.75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
mesna (MESNEX) 490 mg in sodium chloride 0.9 % 50 mL bag
490 mg (250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer just prior to cyclophosphamide. May be be given orally at the physicians discretion.
Mesna dosing optional; delete if not needed
cyclophosphamide (CYTOXAN) 490 mg in sodium chloride 0.9 % 250 mL bag
490 mg (250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Mesna 250 mg/m2 OPTIONAL prior to cyclophosphamide.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 5 - VTC – Planned for 9/9/2017
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Zztestonc,Jeff J [2507481]
6/13/2017 4:04:26 PM Page 24 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Advanced); THERAPY: vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1; topotecan 0.75
mg/m2 IV Day 1 through 5; cyclophosphamide 250 mg/m2 IV Day 1 through 5; mesna 250 mg/m2 IV/by mouth prior to
cyclophosphamide (optional) Day 1 through 5, alternating cycles with vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1;
DACTINOmycin 1.5 mg/m2 (max dose = 2.5 mg) IV Day 1, cyclophosphamide 2200 mg/m2 IV Day 1; mesna 450 mg/m2 IV prior to
cyclophosphamide and 450 mg/m2 by mouth every 3 hours after start of cyclophosphamide for a total of four doses Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 alternating cycles or until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
topotecan (HYCAMTIN) 1.47 mg in sodium chloride 0.9 % 100 mL bag
1.47 mg (0.75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
mesna (MESNEX) 490 mg in sodium chloride 0.9 % 50 mL bag
490 mg (250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer just prior to cyclophosphamide. May be be given orally at the physicians discretion.
Mesna dosing optional; delete if not needed
cyclophosphamide (CYTOXAN) 490 mg in sodium chloride 0.9 % 250 mL bag
490 mg (250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Mesna 250 mg/m2 OPTIONAL prior to cyclophosphamide.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 10, Cycle 5 - VTC – Planned for 9/14/2017
Treatment Plan Information
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Zztestonc,Jeff J [2507481]
6/13/2017 4:04:26 PM Page 25 of 38
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: Rhabdomyosarcoma (Advanced); THERAPY: vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1;
topotecan 0.75 mg/m2 IV Day 1 through 5; cyclophosphamide 250 mg/m2 IV Day 1 through 5; mesna 250 mg/m2
IV/by mouth prior to cyclophosphamide (optional) Day 1 through 5, alternating cycles with vinCRIStine 1.5 mg/m2
(max dose = 2 mg) IV Day 1; DACTINOmycin 1.5 mg/m2 (max dose = 2.5 mg) IV Day 1, cyclophosphamide 2200
mg/m2 IV Day 1; mesna 450 mg/m2 IV prior to cyclophosphamide and 450 mg/m2 by mouth every 3 hours after
start of cyclophosphamide for a total of four doses Day 1; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21
days; COURSE: 6 to 8 alternating cycles or until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+5 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+5 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 6 - VAC – 9/26/2017 through 10/16/2017 (21 days), Planned
Day 1, Cycle 6 - VAC – Planned for 9/26/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Advanced); THERAPY: vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1; topotecan 0.75
mg/m2 IV Day 1 through 5; cyclophosphamide 250 mg/m2 IV Day 1 through 5; mesna 250 mg/m2 IV/by mouth prior to
cyclophosphamide (optional) Day 1 through 5, alternating cycles with vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1;
DACTINOmycin 1.5 mg/m2 (max dose = 2.5 mg) IV Day 1, cyclophosphamide 2200 mg/m2 IV Day 1; mesna 450 mg/m2 IV prior to
cyclophosphamide and 450 mg/m2 by mouth every 3 hours after start of cyclophosphamide for a total of four doses Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 alternating cycles or until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+17 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+17 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+17 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+17 Approximate, Expires-S+365, Routine
BUN
Expected-S+17 Approximate, Expires-S+365, Routine
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Zztestonc,Jeff J [2507481]
6/13/2017 4:04:26 PM Page 26 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

CREATININE
Expected-S+17 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+17 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+17 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+17 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than upper limits of normal.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
vinCRIStine (ONCOVIN) 2.9 mg in sodium chloride 0.9 % 25 mL bag
2.9 mg (rounded from 2.94 mg = 1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3-5 Minutes
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
DACTINOmycin (COSMOGEN) injection 2,940 mcg
2,940 mcg (1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
IV push over 1-5 minutes into running IV. Max dose = 2500 mcg.
mesna (MESNEX) 882 mg in sodium chloride 0.9 % 50 mL bag
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2,500 mcg.
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Zztestonc,Jeff J [2507481]
6/13/2017 4:04:26 PM Page 27 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

882 mg (450 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give prior to start of cyclophosphamide.
cyclophosphamide (CYTOXAN) 4,312 mg bag
4,312 mg (2,200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): mesna oral at 3 hours and 6 hours and 9 hours
after the start of cyclophosphamide.
Take Home Medications
mesna (MESNEX) 400 MG tab
Take 2 tabs by mouth 3 times daily. Take 3h, 6h and 9h after start of cyclophosphamide., 800 mg (rounded from 882 mg = 450
mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-5, 3 X DAILY starting S
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
Verify Day 22 (Day 1 of next cycle) appointments have been scheduled: RETURN TO CLINIC for appointment with provider; LABS:
CBC, ANC (DIFF if to be done locally), Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, Alkaline Phosphatase;
CHEMOTHERAPY ROOM APPOINTMENT: vinCRIStine, topotecan, and cyclophosphamide for 150 minutes.
Lab Only - Day 8, Cycle 6 - VAC – Planned for 10/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Advanced); THERAPY: vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1; topotecan 0.75
mg/m2 IV Day 1 through 5; cyclophosphamide 250 mg/m2 IV Day 1 through 5; mesna 250 mg/m2 IV/by mouth prior to
cyclophosphamide (optional) Day 1 through 5, alternating cycles with vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1;
DACTINOmycin 1.5 mg/m2 (max dose = 2.5 mg) IV Day 1, cyclophosphamide 2200 mg/m2 IV Day 1; mesna 450 mg/m2 IV prior to
cyclophosphamide and 450 mg/m2 by mouth every 3 hours after start of cyclophosphamide for a total of four doses Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 alternating cycles or until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 6 - VAC – Planned for 10/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Advanced); THERAPY: vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1; topotecan 0.75
mg/m2 IV Day 1 through 5; cyclophosphamide 250 mg/m2 IV Day 1 through 5; mesna 250 mg/m2 IV/by mouth prior to
cyclophosphamide (optional) Day 1 through 5, alternating cycles with vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1;
DACTINOmycin 1.5 mg/m2 (max dose = 2.5 mg) IV Day 1, cyclophosphamide 2200 mg/m2 IV Day 1; mesna 450 mg/m2 IV prior to
cyclophosphamide and 450 mg/m2 by mouth every 3 hours after start of cyclophosphamide for a total of four doses Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 alternating cycles or until disease progression.
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Zztestonc,Jeff J [2507481]
6/13/2017 4:04:26 PM Page 28 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 7 - VTC – 10/17/2017 through 11/6/2017 (21 days), Planned
Day 1, Cycle 7 - VTC – Planned for 10/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Advanced); THERAPY: vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1; topotecan 0.75
mg/m2 IV Day 1 through 5; cyclophosphamide 250 mg/m2 IV Day 1 through 5; mesna 250 mg/m2 IV/by mouth prior to
cyclophosphamide (optional) Day 1 through 5, alternating cycles with vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1;
DACTINOmycin 1.5 mg/m2 (max dose = 2.5 mg) IV Day 1, cyclophosphamide 2200 mg/m2 IV Day 1; mesna 450 mg/m2 IV prior to
cyclophosphamide and 450 mg/m2 by mouth every 3 hours after start of cyclophosphamide for a total of four doses Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 alternating cycles or until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S 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
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Zztestonc,Jeff J [2507481]
6/13/2017 4:04:26 PM Page 29 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

ALKALINE PHOSPHATASE
Expected-S Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than upper limits of normal.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
vinCRIStine (ONCOVIN) 2.9 mg in sodium chloride 0.9 % 25 mL bag
2.9 mg (rounded from 2.94 mg = 1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3-5 Minutes
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
topotecan (HYCAMTIN) 1.47 mg in sodium chloride 0.9 % 100 mL bag
1.47 mg (0.75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
mesna (MESNEX) 490 mg in sodium chloride 0.9 % 50 mL bag
490 mg (250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer just prior to cyclophosphamide. May be be given orally at the physicians discretion.
Mesna dosing optional; delete if not needed
cyclophosphamide (CYTOXAN) 490 mg in sodium chloride 0.9 % 250 mL bag
490 mg (250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Mesna 250 mg/m2 OPTIONAL prior to cyclophosphamide.
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: topotecan and cyclophosphamide for 120 minutes.
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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Zztestonc,Jeff J [2507481]
6/13/2017 4:04:26 PM Page 30 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: topotecan and cyclophosphamide for 120 minutes.
DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: topotecan and cyclophosphamide for 120 minutes.
DAY 5 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: topotecan and cyclophosphamide for 120 minutes.
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Electrolytes, Glucose, BUN,
Creatinine, Total Bilirubin, AST, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: vinCRIStine, DACTINOmycin,
and cyclophosphamide for 150 minutes.
Day 2, Cycle 7 - VTC – Planned for 10/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Advanced); THERAPY: vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1; topotecan 0.75
mg/m2 IV Day 1 through 5; cyclophosphamide 250 mg/m2 IV Day 1 through 5; mesna 250 mg/m2 IV/by mouth prior to
cyclophosphamide (optional) Day 1 through 5, alternating cycles with vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1;
DACTINOmycin 1.5 mg/m2 (max dose = 2.5 mg) IV Day 1, cyclophosphamide 2200 mg/m2 IV Day 1; mesna 450 mg/m2 IV prior to
cyclophosphamide and 450 mg/m2 by mouth every 3 hours after start of cyclophosphamide for a total of four doses Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 alternating cycles or until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
topotecan (HYCAMTIN) 1.47 mg in sodium chloride 0.9 % 100 mL bag
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Zztestonc,Jeff J [2507481]
6/13/2017 4:04:26 PM Page 31 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

1.47 mg (0.75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
mesna (MESNEX) 490 mg in sodium chloride 0.9 % 50 mL bag
490 mg (250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer just prior to cyclophosphamide. May be be given orally at the physicians discretion.
Mesna dosing optional; delete if not needed
cyclophosphamide (CYTOXAN) 490 mg in sodium chloride 0.9 % 250 mL bag
490 mg (250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Mesna 250 mg/m2 OPTIONAL prior to cyclophosphamide.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 7 - VTC – Planned for 10/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Advanced); THERAPY: vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1; topotecan 0.75
mg/m2 IV Day 1 through 5; cyclophosphamide 250 mg/m2 IV Day 1 through 5; mesna 250 mg/m2 IV/by mouth prior to
cyclophosphamide (optional) Day 1 through 5, alternating cycles with vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1;
DACTINOmycin 1.5 mg/m2 (max dose = 2.5 mg) IV Day 1, cyclophosphamide 2200 mg/m2 IV Day 1; mesna 450 mg/m2 IV prior to
cyclophosphamide and 450 mg/m2 by mouth every 3 hours after start of cyclophosphamide for a total of four doses Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 alternating cycles or until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
topotecan (HYCAMTIN) 1.47 mg in sodium chloride 0.9 % 100 mL bag
1.47 mg (0.75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
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Zztestonc,Jeff J [2507481]
6/13/2017 4:04:26 PM Page 32 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

mesna (MESNEX) 490 mg in sodium chloride 0.9 % 50 mL bag
490 mg (250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Administer just prior to cyclophosphamide. May be be given orally at the physicians discretion.
Mesna dosing optional; delete if not needed
cyclophosphamide (CYTOXAN) 490 mg in sodium chloride 0.9 % 250 mL bag
490 mg (250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Mesna 250 mg/m2 OPTIONAL prior to cyclophosphamide.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 4, Cycle 7 - VTC – Planned for 10/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Advanced); THERAPY: vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1; topotecan 0.75
mg/m2 IV Day 1 through 5; cyclophosphamide 250 mg/m2 IV Day 1 through 5; mesna 250 mg/m2 IV/by mouth prior to
cyclophosphamide (optional) Day 1 through 5, alternating cycles with vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1;
DACTINOmycin 1.5 mg/m2 (max dose = 2.5 mg) IV Day 1, cyclophosphamide 2200 mg/m2 IV Day 1; mesna 450 mg/m2 IV prior to
cyclophosphamide and 450 mg/m2 by mouth every 3 hours after start of cyclophosphamide for a total of four doses Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 alternating cycles or until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
topotecan (HYCAMTIN) 1.47 mg in sodium chloride 0.9 % 100 mL bag
1.47 mg (0.75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
mesna (MESNEX) 490 mg in sodium chloride 0.9 % 50 mL bag
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Zztestonc,Jeff J [2507481]
6/13/2017 4:04:26 PM Page 33 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

490 mg (250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer just prior to cyclophosphamide. May be be given orally at the physicians discretion.
Mesna dosing optional; delete if not needed
cyclophosphamide (CYTOXAN) 490 mg in sodium chloride 0.9 % 250 mL bag
490 mg (250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Mesna 250 mg/m2 OPTIONAL prior to cyclophosphamide.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 7 - VTC – Planned for 10/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Advanced); THERAPY: vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1; topotecan 0.75
mg/m2 IV Day 1 through 5; cyclophosphamide 250 mg/m2 IV Day 1 through 5; mesna 250 mg/m2 IV/by mouth prior to
cyclophosphamide (optional) Day 1 through 5, alternating cycles with vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1;
DACTINOmycin 1.5 mg/m2 (max dose = 2.5 mg) IV Day 1, cyclophosphamide 2200 mg/m2 IV Day 1; mesna 450 mg/m2 IV prior to
cyclophosphamide and 450 mg/m2 by mouth every 3 hours after start of cyclophosphamide for a total of four doses Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 alternating cycles or until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
topotecan (HYCAMTIN) 1.47 mg in sodium chloride 0.9 % 100 mL bag
1.47 mg (0.75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
mesna (MESNEX) 490 mg in sodium chloride 0.9 % 50 mL bag
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Zztestonc,Jeff J [2507481]
6/13/2017 4:04:26 PM Page 34 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

490 mg (250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer just prior to cyclophosphamide. May be be given orally at the physicians discretion.
Mesna dosing optional; delete if not needed
cyclophosphamide (CYTOXAN) 490 mg in sodium chloride 0.9 % 250 mL bag
490 mg (250 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Mesna 250 mg/m2 OPTIONAL prior to cyclophosphamide.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 10, Cycle 7 - VTC – Planned for 10/26/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Advanced); THERAPY: vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1; topotecan 0.75
mg/m2 IV Day 1 through 5; cyclophosphamide 250 mg/m2 IV Day 1 through 5; mesna 250 mg/m2 IV/by mouth prior to
cyclophosphamide (optional) Day 1 through 5, alternating cycles with vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1;
DACTINOmycin 1.5 mg/m2 (max dose = 2.5 mg) IV Day 1, cyclophosphamide 2200 mg/m2 IV Day 1; mesna 450 mg/m2 IV prior to
cyclophosphamide and 450 mg/m2 by mouth every 3 hours after start of cyclophosphamide for a total of four doses Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 alternating cycles or until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+5 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+5 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 8 - VAC – 11/7/2017 through 11/27/2017 (21 days), Planned
Day 1, Cycle 8 - VAC – Planned for 11/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Advanced); THERAPY: vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1; topotecan 0.75
mg/m2 IV Day 1 through 5; cyclophosphamide 250 mg/m2 IV Day 1 through 5; mesna 250 mg/m2 IV/by mouth prior to
cyclophosphamide (optional) Day 1 through 5, alternating cycles with vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1;
DACTINOmycin 1.5 mg/m2 (max dose = 2.5 mg) IV Day 1, cyclophosphamide 2200 mg/m2 IV Day 1; mesna 450 mg/m2 IV prior to
cyclophosphamide and 450 mg/m2 by mouth every 3 hours after start of cyclophosphamide for a total of four doses Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 alternating cycles or until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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Zztestonc,Jeff J [2507481]
6/13/2017 4:04:26 PM Page 35 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

CBC WITHOUT DIFFERENTIAL
Expected-S+17 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+17 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+17 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+17 Approximate, Expires-S+365, Routine
BUN
Expected-S+17 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+17 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+17 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+17 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+17 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than upper limits of normal.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
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Zztestonc,Jeff J [2507481]
6/13/2017 4:04:26 PM Page 36 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

vinCRIStine (ONCOVIN) 2.9 mg in sodium chloride 0.9 % 25 mL bag
2.9 mg (rounded from 2.94 mg = 1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released, Administer over 3-5 Minutes
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
DACTINOmycin (COSMOGEN) injection 2,940 mcg
2,940 mcg (1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
IV push over 1-5 minutes into running IV. Max dose = 2500 mcg.
mesna (MESNEX) 882 mg in sodium chloride 0.9 % 50 mL bag
882 mg (450 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give prior to start of cyclophosphamide.
cyclophosphamide (CYTOXAN) 4,312 mg bag
4,312 mg (2,200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): mesna oral at 3 hours and 6 hours and 9 hours
after the start of cyclophosphamide.
Take Home Medications
mesna (MESNEX) 400 MG tab
Take 2 tabs by mouth 3 times daily. Take 3h, 6h and 9h after start of cyclophosphamide., 800 mg (rounded from 882 mg = 450
mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-5, 3 X DAILY starting S
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
Verify Day 22 (Day 1 of next cycle) appointments have been scheduled: RETURN TO CLINIC for appointment with provider; LABS:
CBC, ANC (DIFF if to be done locally), Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, Alkaline Phosphatase;
CHEMOTHERAPY ROOM APPOINTMENT: vinCRIStine, topotecan, and cyclophosphamide for 150 minutes.
Lab Only - Day 8, Cycle 8 - VAC – Planned for 11/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Advanced); THERAPY: vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1; topotecan 0.75
mg/m2 IV Day 1 through 5; cyclophosphamide 250 mg/m2 IV Day 1 through 5; mesna 250 mg/m2 IV/by mouth prior to
cyclophosphamide (optional) Day 1 through 5, alternating cycles with vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1;
DACTINOmycin 1.5 mg/m2 (max dose = 2.5 mg) IV Day 1, cyclophosphamide 2200 mg/m2 IV Day 1; mesna 450 mg/m2 IV prior to
cyclophosphamide and 450 mg/m2 by mouth every 3 hours after start of cyclophosphamide for a total of four doses Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 alternating cycles or until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Follow-Up
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2,500 mcg.
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Zztestonc,Jeff J [2507481]
6/13/2017 4:04:26 PM Page 37 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 8 - VAC – Planned for 11/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Rhabdomyosarcoma (Advanced); THERAPY: vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1; topotecan 0.75
mg/m2 IV Day 1 through 5; cyclophosphamide 250 mg/m2 IV Day 1 through 5; mesna 250 mg/m2 IV/by mouth prior to
cyclophosphamide (optional) Day 1 through 5, alternating cycles with vinCRIStine 1.5 mg/m2 (max dose = 2 mg) IV Day 1;
DACTINOmycin 1.5 mg/m2 (max dose = 2.5 mg) IV Day 1, cyclophosphamide 2200 mg/m2 IV Day 1; mesna 450 mg/m2 IV prior to
cyclophosphamide and 450 mg/m2 by mouth every 3 hours after start of cyclophosphamide for a total of four doses Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 to 8 alternating cycles or until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,Jeff J [2507481]
6/13/2017 4:04:26 PM Page 38 of 38
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org