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

/clinical/cckm-tools/content/beacon-protocols/breast/name-96594-en.cckm

201611306

page

100

UWHC,UWMF,

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

CSC Breast Cyclophosphamide(14D:1)/Doxorubicin(14D:1) Followed by Paclitaxel(21D:1,8,15)/Trastuzumab(21D:1,8,15) Followed by Trastuzumab(21D:1) VER: 10-3-16 (HL 5649)

CSC Breast Cyclophosphamide(14D:1)/Doxorubicin(14D:1) Followed by Paclitaxel(21D:1,8,15)/Trastuzumab(21D:1,8,15) Followed by Trastuzumab(21D:1) VER: 10-3-16 (HL 5649) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Breast


CSC BREAST CYCLOPHOSPHAMIDE(14D:1)/DOXORUBICIN(14D:1) FOLLOWED BY PACLITAXEL
(21D:1,8,15)/TRASTUZUMAB(21D:1,8,15) FOLLOWED BY TRASTUZUMAB(21D:1) VER: 10-3-16 – Properties
Pre-Cycle – 10/25/2016 through 10/31/2016 (7 days), Planned
Day 1, Pre-Cycle – Planned for 10/25/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Adjuvant); THERAPY: doxorubicin 60 mg/m2 IV Day 1, cyclophosphamide 600 mg/m2 IV Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 14 days; COURSE: 4 cycles followed by THERAPY: trastuzumab 4 mg/kg IV
Day 1, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15, trastuzumab 2 mg/kg IV Days 8 and 15; CYCLE LENGTH: 21 days; COURSE: 1
cycle followed by THERAPY: trastuzumab 2 mg/kg IV Days 1, 8, and 15, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15; CYCLE
LENGTH: 21 days; COURSE: 3 cycles followed by THERAPY: trastuzumab 6 mg/kg IV Day 1; CYCLE LENGTH: 21 days;
COURSE: 13 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Routine
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
Treatment Conditions
Treatment Condition A
Verify patient has obtained pretreatment MUGA or ECHO.
Take Home Medications
ranitidine (ZANTAC) 150 MG tab
Take 1 tab by mouth 2 times daily., 150 mg, Disp-60 tab, R-5, 2 X DAILY starting S, Local Printer
aprepitant (EMEND) 80 MG cap
Take 1 cap by mouth one time daily. Take for 2 days following chemotherapy., 80 mg, Disp-2 cap, R-3, 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-24 tab, R-0, 1 X DAILY starting S
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed., 8 mg, Disp-30 tab, R-11, EVERY 8 HOURS PRN starting S, Local Printer
Take Home Medications (delete all that do not apply)
TBO-filgrastim (GRANIX) 300 MCG/0.5ML soln prefilled syringe
Inject 300 mcg under skin one time daily in evening. Begin Day ***. Continue until ANC is greater than *** after nadir., 300 mcg,
Disp-10 Syringe, R-5, 1 X DAILY (PM) starting S, Local Printer
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
TBO-filgrastim (GRANIX) 480 MCG/0.8ML soln prefilled syringe
Inject 480 mcg under skin one time daily in evening. Begin Day ***. Continue until ANC is greater than *** after nadir., 480 mcg,
Disp-10 Syringe, R-5, 1 X DAILY (PM) starting S, Local Printer
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
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ZZtestonc,Andrew [2428787]
11/1/2016 3:31:19 PM Page 1 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Cycle 1 – 11/1/2016 through 11/14/2016 (14 days), Planned
Day 1, Cycle 1 – Planned for 11/1/2016
Treatment Plan Information
Reference Information (1)
BREAST CANCER: Citron ML, et al. J Clin Oncol 2003;21:1431-39.
Reference Information (2)
BREAST CANCER: Romond E, et al. N Eng J Med 2005;353(16):1673-84.
Reference Information (3)
BREAST CANCER: Leyland-Jones B, et al. J Clin Oncol 2003;21(21):3965-71.
Treatment Plan Summary
DISEASE: Breast Cancer (Adjuvant); THERAPY: doxorubicin 60 mg/m2 IV Day 1, cyclophosphamide 600 mg/m2 IV Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 14 days; COURSE: 4 cycles followed by THERAPY: trastuzumab 4 mg/kg IV
Day 1, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15, trastuzumab 2 mg/kg IV Days 8 and 15; CYCLE LENGTH: 21 days; COURSE: 1
cycle followed by THERAPY: trastuzumab 2 mg/kg IV Days 1, 8, and 15, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15; CYCLE
LENGTH: 21 days; COURSE: 3 cycles followed by THERAPY: trastuzumab 6 mg/kg IV Day 1; CYCLE LENGTH: 21 days;
COURSE: 13 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL, Platelets less than or equal to 100K/µL, Creatinine
greater than 2 mg/dL, or AST greater than 1.5 X ULN or Total Bilirubin greater than 1.2 mg/dL.
Treatment Condition A
Verify patient has obtained pretreatment MUGA or ECHO.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
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 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
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ZZtestonc,Andrew [2428787]
11/1/2016 3:31:19 PM Page 2 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 60 mg/m2 (Treatment Plan)
60 mg/m2, Intravenous, ONCE, 1 dose Starting when released
IV side arm push 3-5 mL/minute into running IV.
cyclophosphamide (CYTOXAN) 600 mg/m2 in sodium chloride 0.9 % 250 mL bag
600 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes.
Follow-Up
DAY 15 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine,
AST, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin and cyclophosphamide for 90 minutes.
Cycle 2 – 11/15/2016 through 11/28/2016 (14 days), Planned
Day 1, Cycle 2 – Planned for 11/15/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Adjuvant); THERAPY: doxorubicin 60 mg/m2 IV Day 1, cyclophosphamide 600 mg/m2 IV Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 14 days; COURSE: 4 cycles followed by THERAPY: trastuzumab 4 mg/kg IV
Day 1, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15, trastuzumab 2 mg/kg IV Days 8 and 15; CYCLE LENGTH: 21 days; COURSE: 1
cycle followed by THERAPY: trastuzumab 2 mg/kg IV Days 1, 8, and 15, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15; CYCLE
LENGTH: 21 days; COURSE: 3 cycles followed by THERAPY: trastuzumab 6 mg/kg IV Day 1; CYCLE LENGTH: 21 days;
COURSE: 13 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
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ZZtestonc,Andrew [2428787]
11/1/2016 3:31:19 PM Page 3 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL, Platelets less than or equal to 100K/µL, Creatinine
greater than 2 mg/dL, or AST greater than 1.5 X ULN or Total Bilirubin greater than 1.2 mg/dL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
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 10 UNIT/ML lock flush 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
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 60 mg/m2 (Treatment Plan)
60 mg/m2, Intravenous, ONCE, 1 dose Starting when released
IV side arm push 3-5 mL/minute into running IV.
cyclophosphamide (CYTOXAN) 600 mg/m2 in sodium chloride 0.9 % 250 mL bag
600 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes.
Follow-Up
DAY 15 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine,
AST, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin and cyclophosphamide for 90 minutes.
Cycle 3 – 11/29/2016 through 12/12/2016 (14 days), Planned
Day 1, Cycle 3 – Planned for 11/29/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Adjuvant); THERAPY: doxorubicin 60 mg/m2 IV Day 1, cyclophosphamide 600 mg/m2 IV Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 14 days; COURSE: 4 cycles followed by THERAPY: trastuzumab 4 mg/kg IV
Day 1, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15, trastuzumab 2 mg/kg IV Days 8 and 15; CYCLE LENGTH: 21 days; COURSE: 1
cycle followed by THERAPY: trastuzumab 2 mg/kg IV Days 1, 8, and 15, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15; CYCLE
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ZZtestonc,Andrew [2428787]
11/1/2016 3:31:19 PM Page 4 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

LENGTH: 21 days; COURSE: 3 cycles followed by THERAPY: trastuzumab 6 mg/kg IV Day 1; CYCLE LENGTH: 21 days;
COURSE: 13 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL, Platelets less than or equal to 100K/µL, Creatinine
greater than 2 mg/dL, or AST greater than 1.5 X ULN or Total Bilirubin greater than 1.2 mg/dL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
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 10 UNIT/ML lock flush 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
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ZZtestonc,Andrew [2428787]
11/1/2016 3:31:19 PM Page 5 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 60 mg/m2 (Treatment Plan)
60 mg/m2, Intravenous, ONCE, 1 dose Starting when released
IV side arm push 3-5 mL/minute into running IV.
cyclophosphamide (CYTOXAN) 600 mg/m2 in sodium chloride 0.9 % 250 mL bag
600 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes.
Follow-Up
DAY 15 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine,
AST, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin and cyclophosphamide for 90 minutes.
Cycle 4 – 12/13/2016 through 12/26/2016 (14 days), Planned
Day 1, Cycle 4 – Planned for 12/13/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Adjuvant); THERAPY: doxorubicin 60 mg/m2 IV Day 1, cyclophosphamide 600 mg/m2 IV Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 14 days; COURSE: 4 cycles followed by THERAPY: trastuzumab 4 mg/kg IV
Day 1, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15, trastuzumab 2 mg/kg IV Days 8 and 15; CYCLE LENGTH: 21 days; COURSE: 1
cycle followed by THERAPY: trastuzumab 2 mg/kg IV Days 1, 8, and 15, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15; CYCLE
LENGTH: 21 days; COURSE: 3 cycles followed by THERAPY: trastuzumab 6 mg/kg IV Day 1; CYCLE LENGTH: 21 days;
COURSE: 13 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL, Platelets less than or equal to 100K/µL, Creatinine
greater than 2 mg/dL, or AST greater than 1.5 X ULN or Total Bilirubin greater than 1.2 mg/dL.
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ZZtestonc,Andrew [2428787]
11/1/2016 3:31:19 PM Page 6 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
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 10 UNIT/ML lock flush 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
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 60 mg/m2 (Treatment Plan)
60 mg/m2, Intravenous, ONCE, 1 dose Starting when released
IV side arm push 3-5 mL/minute into running IV.
cyclophosphamide (CYTOXAN) 600 mg/m2 in sodium chloride 0.9 % 250 mL bag
600 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes.
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
Take 5 tabs by mouth 2 times daily. Take 12 hours and 6 hours prior to PACLItaxel for 2 doses., 20 mg, Disp-10 tab, R-0, 2 X
DAILY starting S
Follow-Up
DAY 15 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine,
AST, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: trastuzumab and PACLItaxel for 180 minutes.
Cycle 5 – 12/27/2016 through 1/16/2017 (21 days), Planned
Day 1, Cycle 5 – Planned for 12/27/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Adjuvant); THERAPY: doxorubicin 60 mg/m2 IV Day 1, cyclophosphamide 600 mg/m2 IV Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 14 days; COURSE: 4 cycles followed by THERAPY: trastuzumab 4 mg/kg IV
Day 1, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15, trastuzumab 2 mg/kg IV Days 8 and 15; CYCLE LENGTH: 21 days; COURSE: 1
cycle followed by THERAPY: trastuzumab 2 mg/kg IV Days 1, 8, and 15, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15; CYCLE
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ZZtestonc,Andrew [2428787]
11/1/2016 3:31:19 PM Page 7 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

LENGTH: 21 days; COURSE: 3 cycles followed by THERAPY: trastuzumab 6 mg/kg IV Day 1; CYCLE LENGTH: 21 days;
COURSE: 13 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than 1.5 X ULN, or Total Bilirubin greater than or equal to 1.25 X ULN or AST greater than or equal to 5 X ULN.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to trastuzumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient must be monitored for one hour after the first dose of trastuzumab. See Emergency Medications.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 18mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
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 10 UNIT/ML lock flush injection 1-150 units
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ZZtestonc,Andrew [2428787]
11/1/2016 3:31:19 PM Page 8 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
trastuzumab (HERCEPTIN) 318 mg in sodium chloride 0.9 % 250 mL bag
318 mg (rounded from 317.6 mg = 4 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy. Give first dose over
60 minutes and subsequent doses over 30 minutes. Patient must be monitored for one hour after the first dose of trastuzumab.
PACLItaxel (TAXOL) 80 mg/m2 in dextrose 5 % 100 mL non-PVC bag
80 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Infuse through non-PVC containing tubing and 0.22 micron in-line non-DEHP (non-PVC) filter during administration. Administer over
60 minutes. Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
Take 3 tabs 12&6 hrs prior to 2nd PACLItaxel dose and 2 tabs 12&6 hrs prior to remaining PACLItaxel doses., Disp-50 tab, R-1,
starting S
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally); CHEMOTHERAPY ROOM APPOINTMENT: trastuzumab and PACLItaxel for 120 minutes.
DAY 15 FOLLOW-UP
LABS: CBC,ANC (DIFF of done locally); CHEMOTHERAPY ROOM APPOINTMENT: trastuzumab and PACLItaxel for 120 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Creatinine, Total
Bilirubin, AST; CHEMOTHERAPY ROOM APPOINTMENT: trastuzumab and PACLItaxel for 120 minutes.
Day 8, Cycle 5 – Planned for 1/3/2017
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ZZtestonc,Andrew [2428787]
11/1/2016 3:31:19 PM Page 9 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Adjuvant); THERAPY: doxorubicin 60 mg/m2 IV Day 1, cyclophosphamide 600 mg/m2 IV Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 14 days; COURSE: 4 cycles followed by THERAPY: trastuzumab 4 mg/kg IV
Day 1, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15, trastuzumab 2 mg/kg IV Days 8 and 15; CYCLE LENGTH: 21 days; COURSE: 1
cycle followed by THERAPY: trastuzumab 2 mg/kg IV Days 1, 8, and 15, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15; CYCLE
LENGTH: 21 days; COURSE: 3 cycles followed by THERAPY: trastuzumab 6 mg/kg IV Day 1; CYCLE LENGTH: 21 days;
COURSE: 13 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to trastuzumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient must be monitored for one hour after the first dose of trastuzumab. See Emergency Medications.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 18mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
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 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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ZZtestonc,Andrew [2428787]
11/1/2016 3:31:19 PM Page 10 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Pre-Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
trastuzumab (HERCEPTIN) 159 mg in sodium chloride 0.9 % 250 mL bag
159 mg (rounded from 158.8 mg = 2 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy. Give first dose over
60 minutes and subsequent doses over 30 minutes. Patient must be monitored for one hour after the first dose of trastuzumab.
PACLItaxel (TAXOL) 80 mg/m2 in dextrose 5 % 100 mL non-PVC bag
80 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Infuse through non-PVC containing tubing and 0.22 micron in-line non-DEHP (non-PVC) filter during administration. Administer over
60 minutes. Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 5 – Planned for 1/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Adjuvant); THERAPY: doxorubicin 60 mg/m2 IV Day 1, cyclophosphamide 600 mg/m2 IV Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 14 days; COURSE: 4 cycles followed by THERAPY: trastuzumab 4 mg/kg IV
Day 1, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15, trastuzumab 2 mg/kg IV Days 8 and 15; CYCLE LENGTH: 21 days; COURSE: 1
cycle followed by THERAPY: trastuzumab 2 mg/kg IV Days 1, 8, and 15, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15; CYCLE
LENGTH: 21 days; COURSE: 3 cycles followed by THERAPY: trastuzumab 6 mg/kg IV Day 1; CYCLE LENGTH: 21 days;
COURSE: 13 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
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ZZtestonc,Andrew [2428787]
11/1/2016 3:31:19 PM Page 11 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Conditions
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to trastuzumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient must be monitored for one hour after the first dose of trastuzumab. See Emergency Medications.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 18mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
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 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
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ZZtestonc,Andrew [2428787]
11/1/2016 3:31:19 PM Page 12 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
trastuzumab (HERCEPTIN) 159 mg in sodium chloride 0.9 % 250 mL bag
159 mg (rounded from 158.8 mg = 2 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy. Give first dose over
60 minutes and subsequent doses over 30 minutes. Patient must be monitored for one hour after the first dose of trastuzumab.
PACLItaxel (TAXOL) 80 mg/m2 in dextrose 5 % 100 mL non-PVC bag
80 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Infuse through non-PVC containing tubing and 0.22 micron in-line non-DEHP (non-PVC) filter during administration. Administer over
60 minutes. Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 6 – 1/17/2017 through 2/6/2017 (21 days), Planned
Day 1, Cycle 6 – Planned for 1/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Adjuvant); THERAPY: doxorubicin 60 mg/m2 IV Day 1, cyclophosphamide 600 mg/m2 IV Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 14 days; COURSE: 4 cycles followed by THERAPY: trastuzumab 4 mg/kg IV
Day 1, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15, trastuzumab 2 mg/kg IV Days 8 and 15; CYCLE LENGTH: 21 days; COURSE: 1
cycle followed by THERAPY: trastuzumab 2 mg/kg IV Days 1, 8, and 15, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15; CYCLE
LENGTH: 21 days; COURSE: 3 cycles followed by THERAPY: trastuzumab 6 mg/kg IV Day 1; CYCLE LENGTH: 21 days;
COURSE: 13 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, Total Bilirubin.
Treatment Parameters
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ZZtestonc,Andrew [2428787]
11/1/2016 3:31:19 PM Page 13 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than 1.5 X ULN, or Total Bilirubin greater than or equal to 1.25 X ULN or AST greater than or equal to 5 X ULN.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to trastuzumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient must be monitored for one hour after the first dose of trastuzumab. See Emergency Medications.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 18mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
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 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
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ZZtestonc,Andrew [2428787]
11/1/2016 3:31:19 PM Page 14 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Medications
trastuzumab (HERCEPTIN) 159 mg in sodium chloride 0.9 % 250 mL bag
159 mg (rounded from 158.8 mg = 2 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy. Give first dose over
60 minutes and subsequent doses over 30 minutes. Patient must be monitored for one hour after the first dose of trastuzumab.
PACLItaxel (TAXOL) 80 mg/m2 in dextrose 5 % 100 mL non-PVC bag
80 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Infuse through non-PVC containing tubing and 0.22 micron in-line non-DEHP (non-PVC) filter during administration. Administer over
60 minutes. Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
Take 3 tabs 12&6 hrs prior to 2nd PACLItaxel dose and 2 tabs 12&6 hrs prior to remaining PACLItaxel doses., Disp-50 tab, R-1,
starting S
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally); CHEMOTHERAPY ROOM APPOINTMENT: trastuzumab and PACLItaxel for 120 minutes.
DAY 15 FOLLOW-UP
LABS: CBC,ANC (DIFF of done locally); CHEMOTHERAPY ROOM APPOINTMENT: trastuzumab and PACLItaxel for 120 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Creatinine, Total
Bilirubin, AST; CHEMOTHERAPY ROOM APPOINTMENT: trastuzumab and PACLItaxel for 120 minutes.
Day 8, Cycle 6 – Planned for 1/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Adjuvant); THERAPY: doxorubicin 60 mg/m2 IV Day 1, cyclophosphamide 600 mg/m2 IV Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 14 days; COURSE: 4 cycles followed by THERAPY: trastuzumab 4 mg/kg IV
Day 1, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15, trastuzumab 2 mg/kg IV Days 8 and 15; CYCLE LENGTH: 21 days; COURSE: 1
cycle followed by THERAPY: trastuzumab 2 mg/kg IV Days 1, 8, and 15, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15; CYCLE
LENGTH: 21 days; COURSE: 3 cycles followed by THERAPY: trastuzumab 6 mg/kg IV Day 1; CYCLE LENGTH: 21 days;
COURSE: 13 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
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ZZtestonc,Andrew [2428787]
11/1/2016 3:31:19 PM Page 15 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Hypersensitivity reaction to trastuzumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient must be monitored for one hour after the first dose of trastuzumab. See Emergency Medications.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 18mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
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 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
trastuzumab (HERCEPTIN) 159 mg in sodium chloride 0.9 % 250 mL bag
159 mg (rounded from 158.8 mg = 2 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy. Give first dose over
60 minutes and subsequent doses over 30 minutes. Patient must be monitored for one hour after the first dose of trastuzumab.
PACLItaxel (TAXOL) 80 mg/m2 in dextrose 5 % 100 mL non-PVC bag
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ZZtestonc,Andrew [2428787]
11/1/2016 3:31:19 PM Page 16 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

80 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Infuse through non-PVC containing tubing and 0.22 micron in-line non-DEHP (non-PVC) filter during administration. Administer over
60 minutes. Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 6 – Planned for 1/31/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Adjuvant); THERAPY: doxorubicin 60 mg/m2 IV Day 1, cyclophosphamide 600 mg/m2 IV Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 14 days; COURSE: 4 cycles followed by THERAPY: trastuzumab 4 mg/kg IV
Day 1, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15, trastuzumab 2 mg/kg IV Days 8 and 15; CYCLE LENGTH: 21 days; COURSE: 1
cycle followed by THERAPY: trastuzumab 2 mg/kg IV Days 1, 8, and 15, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15; CYCLE
LENGTH: 21 days; COURSE: 3 cycles followed by THERAPY: trastuzumab 6 mg/kg IV Day 1; CYCLE LENGTH: 21 days;
COURSE: 13 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to trastuzumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient must be monitored for one hour after the first dose of trastuzumab. See Emergency Medications.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 18mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
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 10 UNIT/ML lock flush injection 1-150 units
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ZZtestonc,Andrew [2428787]
11/1/2016 3:31:19 PM Page 17 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
trastuzumab (HERCEPTIN) 159 mg in sodium chloride 0.9 % 250 mL bag
159 mg (rounded from 158.8 mg = 2 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy. Give first dose over
60 minutes and subsequent doses over 30 minutes. Patient must be monitored for one hour after the first dose of trastuzumab.
PACLItaxel (TAXOL) 80 mg/m2 in dextrose 5 % 100 mL non-PVC bag
80 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Infuse through non-PVC containing tubing and 0.22 micron in-line non-DEHP (non-PVC) filter during administration. Administer over
60 minutes. Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 7 – 2/7/2017 through 2/27/2017 (21 days), Planned
Day 1, Cycle 7 – Planned for 2/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Adjuvant); THERAPY: doxorubicin 60 mg/m2 IV Day 1, cyclophosphamide 600 mg/m2 IV Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 14 days; COURSE: 4 cycles followed by THERAPY: trastuzumab 4 mg/kg IV
Day 1, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15, trastuzumab 2 mg/kg IV Days 8 and 15; CYCLE LENGTH: 21 days; COURSE: 1
cycle followed by THERAPY: trastuzumab 2 mg/kg IV Days 1, 8, and 15, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15; CYCLE
LENGTH: 21 days; COURSE: 3 cycles followed by THERAPY: trastuzumab 6 mg/kg IV Day 1; CYCLE LENGTH: 21 days;
COURSE: 13 cycles.
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ZZtestonc,Andrew [2428787]
11/1/2016 3:31:19 PM Page 18 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than 1.5 X ULN, or Total Bilirubin greater than or equal to 1.25 X ULN or AST greater than or equal to 5 X ULN.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to trastuzumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient must be monitored for one hour after the first dose of trastuzumab. See Emergency Medications.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 18mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
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 10 UNIT/ML lock flush 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,Andrew [2428787]
11/1/2016 3:31:19 PM Page 19 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
trastuzumab (HERCEPTIN) 159 mg in sodium chloride 0.9 % 250 mL bag
159 mg (rounded from 158.8 mg = 2 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy. Give first dose over
60 minutes and subsequent doses over 30 minutes. Patient must be monitored for one hour after the first dose of trastuzumab.
PACLItaxel (TAXOL) 80 mg/m2 in dextrose 5 % 100 mL non-PVC bag
80 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Infuse through non-PVC containing tubing and 0.22 micron in-line non-DEHP (non-PVC) filter during administration. Administer over
60 minutes. Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
Take 3 tabs 12&6 hrs prior to 2nd PACLItaxel dose and 2 tabs 12&6 hrs prior to remaining PACLItaxel doses., Disp-50 tab, R-1,
starting S
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally); CHEMOTHERAPY ROOM APPOINTMENT: trastuzumab and PACLItaxel for 120 minutes.
DAY 15 FOLLOW-UP
LABS: CBC,ANC (DIFF of done locally); CHEMOTHERAPY ROOM APPOINTMENT: trastuzumab and PACLItaxel for 120 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Creatinine, Total
Bilirubin, AST; CHEMOTHERAPY ROOM APPOINTMENT: trastuzumab and PACLItaxel for 120 minutes.
Day 8, Cycle 7 – Planned for 2/14/2017
Treatment Plan Information
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ZZtestonc,Andrew [2428787]
11/1/2016 3:31:19 PM Page 20 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Breast Cancer (Adjuvant); THERAPY: doxorubicin 60 mg/m2 IV Day 1, cyclophosphamide 600 mg/m2
IV Day 1; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 14 days; COURSE: 4 cycles followed by THERAPY:
trastuzumab 4 mg/kg IV Day 1, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15, trastuzumab 2 mg/kg IV Days 8 and 15;
CYCLE LENGTH: 21 days; COURSE: 1 cycle followed by THERAPY: trastuzumab 2 mg/kg IV Days 1, 8, and 15,
PACLItaxel 80 mg/m2 IV Days 1, 8, and 15; CYCLE LENGTH: 21 days; COURSE: 3 cycles followed by THERAPY:
trastuzumab 6 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 13 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to trastuzumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient must be monitored for one hour after the first dose of trastuzumab. See Emergency Medications.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 18mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
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 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
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ZZtestonc,Andrew [2428787]
11/1/2016 3:31:19 PM Page 21 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
trastuzumab (HERCEPTIN) 159 mg in sodium chloride 0.9 % 250 mL bag
159 mg (rounded from 158.8 mg = 2 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy. Give first dose over
60 minutes and subsequent doses over 30 minutes. Patient must be monitored for one hour after the first dose of trastuzumab.
PACLItaxel (TAXOL) 80 mg/m2 in dextrose 5 % 100 mL non-PVC bag
80 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Infuse through non-PVC containing tubing and 0.22 micron in-line non-DEHP (non-PVC) filter during administration. Administer over
60 minutes. Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 7 – Planned for 2/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Adjuvant); THERAPY: doxorubicin 60 mg/m2 IV Day 1, cyclophosphamide 600 mg/m2 IV Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 14 days; COURSE: 4 cycles followed by THERAPY: trastuzumab 4 mg/kg IV
Day 1, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15, trastuzumab 2 mg/kg IV Days 8 and 15; CYCLE LENGTH: 21 days; COURSE: 1
cycle followed by THERAPY: trastuzumab 2 mg/kg IV Days 1, 8, and 15, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15; CYCLE
LENGTH: 21 days; COURSE: 3 cycles followed by THERAPY: trastuzumab 6 mg/kg IV Day 1; CYCLE LENGTH: 21 days;
COURSE: 13 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
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ZZtestonc,Andrew [2428787]
11/1/2016 3:31:19 PM Page 22 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to trastuzumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient must be monitored for one hour after the first dose of trastuzumab. See Emergency Medications.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 18mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
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 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
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ZZtestonc,Andrew [2428787]
11/1/2016 3:31:19 PM Page 23 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
trastuzumab (HERCEPTIN) 159 mg in sodium chloride 0.9 % 250 mL bag
159 mg (rounded from 158.8 mg = 2 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy. Give first dose over
60 minutes and subsequent doses over 30 minutes. Patient must be monitored for one hour after the first dose of trastuzumab.
PACLItaxel (TAXOL) 80 mg/m2 in dextrose 5 % 100 mL non-PVC bag
80 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Infuse through non-PVC containing tubing and 0.22 micron in-line non-DEHP (non-PVC) filter during administration. Administer over
60 minutes. Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 8 – 2/28/2017 through 3/20/2017 (21 days), Planned
Day 1, Cycle 8 – Planned for 2/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Adjuvant); THERAPY: doxorubicin 60 mg/m2 IV Day 1, cyclophosphamide 600 mg/m2 IV Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 14 days; COURSE: 4 cycles followed by THERAPY: trastuzumab 4 mg/kg IV
Day 1, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15, trastuzumab 2 mg/kg IV Days 8 and 15; CYCLE LENGTH: 21 days; COURSE: 1
cycle followed by THERAPY: trastuzumab 2 mg/kg IV Days 1, 8, and 15, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15; CYCLE
LENGTH: 21 days; COURSE: 3 cycles followed by THERAPY: trastuzumab 6 mg/kg IV Day 1; CYCLE LENGTH: 21 days;
COURSE: 13 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than 1.5 X ULN, or Total Bilirubin greater than or equal to 1.25 X ULN or AST greater than or equal to 5 X ULN.
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ZZtestonc,Andrew [2428787]
11/1/2016 3:31:19 PM Page 24 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if
patient has not taken medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to trastuzumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient must be monitored for one hour after the first dose of trastuzumab. See Emergency Medications.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 18mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
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 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
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ZZtestonc,Andrew [2428787]
11/1/2016 3:31:19 PM Page 25 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

trastuzumab (HERCEPTIN) 159 mg in sodium chloride 0.9 % 250 mL bag
159 mg (rounded from 158.8 mg = 2 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy.
Give first dose over 60 minutes and subsequent doses over 30 minutes. Patient must be monitored for one hour
after the first dose of trastuzumab.
PACLItaxel (TAXOL) 80 mg/m2 in dextrose 5 % 100 mL non-PVC bag
80 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Infuse through non-PVC containing tubing and 0.22 micron in-line non-DEHP (non-PVC) filter during administration. Administer over
60 minutes. Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC,ANC (DIFF if done locally); CHEMOTHERAPY ROOM APPOINTMENT: trastuzumab and PACLItaxel for 120 minutes.
DAY 15 FOLLOW-UP
LABS: CBC,ANC (DIFF of done locally); CHEMOTHERAPY ROOM APPOINTMENT: trastuzumab and PACLItaxel for 120 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; CHEMOTHERAPY ROOM APPOINTMENT for
trastuzumab for 30 minutes.
Day 8, Cycle 8 – Planned for 3/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Adjuvant); THERAPY: doxorubicin 60 mg/m2 IV Day 1, cyclophosphamide 600 mg/m2 IV Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 14 days; COURSE: 4 cycles followed by THERAPY: trastuzumab 4 mg/kg IV
Day 1, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15, trastuzumab 2 mg/kg IV Days 8 and 15; CYCLE LENGTH: 21 days; COURSE: 1
cycle followed by THERAPY: trastuzumab 2 mg/kg IV Days 1, 8, and 15, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15; CYCLE
LENGTH: 21 days; COURSE: 3 cycles followed by THERAPY: trastuzumab 6 mg/kg IV Day 1; CYCLE LENGTH: 21 days;
COURSE: 13 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to trastuzumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient must be monitored for one hour after the first dose of trastuzumab. See Emergency Medications.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 18mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
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ZZtestonc,Andrew [2428787]
11/1/2016 3:31:19 PM Page 26 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
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 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
trastuzumab (HERCEPTIN) 159 mg in sodium chloride 0.9 % 250 mL bag
159 mg (rounded from 158.8 mg = 2 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy. Give first dose over
60 minutes and subsequent doses over 30 minutes. Patient must be monitored for one hour after the first dose of trastuzumab.
PACLItaxel (TAXOL) 80 mg/m2 in dextrose 5 % 100 mL non-PVC bag
80 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Infuse through non-PVC containing tubing and 0.22 micron in-line non-DEHP (non-PVC) filter during administration. Administer over
60 minutes. Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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ZZtestonc,Andrew [2428787]
11/1/2016 3:31:19 PM Page 27 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Day 15, Cycle 8 – Planned for 3/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Adjuvant); THERAPY: doxorubicin 60 mg/m2 IV Day 1, cyclophosphamide 600 mg/m2 IV Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 14 days; COURSE: 4 cycles followed by THERAPY: trastuzumab 4 mg/kg IV
Day 1, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15, trastuzumab 2 mg/kg IV Days 8 and 15; CYCLE LENGTH: 21 days; COURSE: 1
cycle followed by THERAPY: trastuzumab 2 mg/kg IV Days 1, 8, and 15, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15; CYCLE
LENGTH: 21 days; COURSE: 3 cycles followed by THERAPY: trastuzumab 6 mg/kg IV Day 1; CYCLE LENGTH: 21 days;
COURSE: 13 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to trastuzumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient must be monitored for one hour after the first dose of trastuzumab. See Emergency Medications.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
** Rush dextrose primed line with 18mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
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 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
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ZZtestonc,Andrew [2428787]
11/1/2016 3:31:19 PM Page 28 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
trastuzumab (HERCEPTIN) 159 mg in sodium chloride 0.9 % 250 mL bag
159 mg (rounded from 158.8 mg = 2 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy. Give first dose over
60 minutes and subsequent doses over 30 minutes. Patient must be monitored for one hour after the first dose of trastuzumab.
PACLItaxel (TAXOL) 80 mg/m2 in dextrose 5 % 100 mL non-PVC bag
80 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Infuse through non-PVC containing tubing and 0.22 micron in-line non-DEHP (non-PVC) filter during administration. Administer over
60 minutes. Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 9 – 3/21/2017 through 4/10/2017 (21 days), Planned
Day 1, Cycle 9 – Planned for 3/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Adjuvant); THERAPY: doxorubicin 60 mg/m2 IV Day 1, cyclophosphamide 600 mg/m2 IV Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 14 days; COURSE: 4 cycles followed by THERAPY: trastuzumab 4 mg/kg IV
Day 1, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15, trastuzumab 2 mg/kg IV Days 8 and 15; CYCLE LENGTH: 21 days; COURSE: 1
cycle followed by THERAPY: trastuzumab 2 mg/kg IV Days 1, 8, and 15, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15; CYCLE
LENGTH: 21 days; COURSE: 3 cycles followed by THERAPY: trastuzumab 6 mg/kg IV Day 1; CYCLE LENGTH: 21 days;
COURSE: 13 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/1/2016 3:31:19 PM Page 29 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@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
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to trastuzumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient must be monitored for one hour after the first dose of trastuzumab. See Emergency Medications.
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 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
trastuzumab (HERCEPTIN) 476 mg in sodium chloride 0.9 % 250 mL bag
476 mg (rounded from 476.4 mg = 6 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care. See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy. Patient must be
monitored for one hour after the first dose of trastuzumab.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; CHEMOTHERAPY ROOM APPOINTMENT: trastuzumab
for 60 minutes.
Cycle 10 – 4/11/2017 through 5/1/2017 (21 days), Planned
Day 1, Cycle 10 – Planned for 4/11/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Adjuvant); THERAPY: doxorubicin 60 mg/m2 IV Day 1, cyclophosphamide 600 mg/m2 IV Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 14 days; COURSE: 4 cycles followed by THERAPY: trastuzumab 4 mg/kg IV
Day 1, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15, trastuzumab 2 mg/kg IV Days 8 and 15; CYCLE LENGTH: 21 days; COURSE: 1
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ZZtestonc,Andrew [2428787]
11/1/2016 3:31:19 PM Page 30 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

cycle followed by THERAPY: trastuzumab 2 mg/kg IV Days 1, 8, and 15, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15; CYCLE
LENGTH: 21 days; COURSE: 3 cycles followed by THERAPY: trastuzumab 6 mg/kg IV Day 1; CYCLE LENGTH: 21 days;
COURSE: 13 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to trastuzumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient must be monitored for one hour after the first dose of trastuzumab. See Emergency Medications.
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 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
trastuzumab (HERCEPTIN) 476 mg in sodium chloride 0.9 % 250 mL bag
476 mg (rounded from 476.4 mg = 6 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care. See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy. Patient must be
monitored for one hour after the first dose of trastuzumab.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; CHEMOTHERAPY ROOM APPOINTMENT: trastuzumab
for 60 minutes.
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ZZtestonc,Andrew [2428787]
11/1/2016 3:31:19 PM Page 31 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Cycle 11 – 5/2/2017 through 5/22/2017 (21 days), Planned
Day 1, Cycle 11 – Planned for 5/2/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Adjuvant); THERAPY: doxorubicin 60 mg/m2 IV Day 1, cyclophosphamide 600 mg/m2 IV Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 14 days; COURSE: 4 cycles followed by THERAPY: trastuzumab 4 mg/kg IV
Day 1, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15, trastuzumab 2 mg/kg IV Days 8 and 15; CYCLE LENGTH: 21 days; COURSE: 1
cycle followed by THERAPY: trastuzumab 2 mg/kg IV Days 1, 8, and 15, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15; CYCLE
LENGTH: 21 days; COURSE: 3 cycles followed by THERAPY: trastuzumab 6 mg/kg IV Day 1; CYCLE LENGTH: 21 days;
COURSE: 13 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to trastuzumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient must be monitored for one hour after the first dose of trastuzumab. See Emergency Medications.
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 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
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ZZtestonc,Andrew [2428787]
11/1/2016 3:31:19 PM Page 32 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

trastuzumab (HERCEPTIN) 476 mg in sodium chloride 0.9 % 250 mL bag
476 mg (rounded from 476.4 mg = 6 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Hypersensitivity risk. For first and second dose, patient should be treated in a location
to optimize emergency care. See emergency medications. Trastuzumab should be given PRIOR to any
chemotherapy. Patient must be monitored for one hour after the first dose of trastuzumab.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; CHEMOTHERAPY ROOM APPOINTMENT: trastuzumab
for 60 minutes.
Cycle 12 – 5/23/2017 through 6/12/2017 (21 days), Planned
Day 1, Cycle 12 – Planned for 5/23/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Adjuvant); THERAPY: doxorubicin 60 mg/m2 IV Day 1, cyclophosphamide 600 mg/m2 IV Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 14 days; COURSE: 4 cycles followed by THERAPY: trastuzumab 4 mg/kg IV
Day 1, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15, trastuzumab 2 mg/kg IV Days 8 and 15; CYCLE LENGTH: 21 days; COURSE: 1
cycle followed by THERAPY: trastuzumab 2 mg/kg IV Days 1, 8, and 15, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15; CYCLE
LENGTH: 21 days; COURSE: 3 cycles followed by THERAPY: trastuzumab 6 mg/kg IV Day 1; CYCLE LENGTH: 21 days;
COURSE: 13 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to trastuzumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient must be monitored for one hour after the first dose of trastuzumab. See Emergency Medications.
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 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
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ZZtestonc,Andrew [2428787]
11/1/2016 3:31:19 PM Page 33 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
trastuzumab (HERCEPTIN) 476 mg in sodium chloride 0.9 % 250 mL bag
476 mg (rounded from 476.4 mg = 6 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care. See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy. Patient must be
monitored for one hour after the first dose of trastuzumab.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; CHEMOTHERAPY ROOM APPOINTMENT: trastuzumab
for 60 minutes.
Cycle 13 – 6/13/2017 through 7/3/2017 (21 days), Planned
Day 1, Cycle 13 – Planned for 6/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Adjuvant); THERAPY: doxorubicin 60 mg/m2 IV Day 1, cyclophosphamide 600 mg/m2 IV Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 14 days; COURSE: 4 cycles followed by THERAPY: trastuzumab 4 mg/kg IV
Day 1, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15, trastuzumab 2 mg/kg IV Days 8 and 15; CYCLE LENGTH: 21 days; COURSE: 1
cycle followed by THERAPY: trastuzumab 2 mg/kg IV Days 1, 8, and 15, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15; CYCLE
LENGTH: 21 days; COURSE: 3 cycles followed by THERAPY: trastuzumab 6 mg/kg IV Day 1; CYCLE LENGTH: 21 days;
COURSE: 13 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to trastuzumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient must be monitored for one hour after the first dose of trastuzumab. See Emergency Medications.
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 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
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ZZtestonc,Andrew [2428787]
11/1/2016 3:31:19 PM Page 34 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
trastuzumab (HERCEPTIN) 476 mg in sodium chloride 0.9 % 250 mL bag
476 mg (rounded from 476.4 mg = 6 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care. See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy. Patient must be
monitored for one hour after the first dose of trastuzumab.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; CHEMOTHERAPY ROOM APPOINTMENT: trastuzumab
for 60 minutes.
Cycle 14 – 7/4/2017 through 7/24/2017 (21 days), Planned
Day 1, Cycle 14 – Planned for 7/4/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Adjuvant); THERAPY: doxorubicin 60 mg/m2 IV Day 1, cyclophosphamide 600 mg/m2 IV Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 14 days; COURSE: 4 cycles followed by THERAPY: trastuzumab 4 mg/kg IV
Day 1, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15, trastuzumab 2 mg/kg IV Days 8 and 15; CYCLE LENGTH: 21 days; COURSE: 1
cycle followed by THERAPY: trastuzumab 2 mg/kg IV Days 1, 8, and 15, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15; CYCLE
LENGTH: 21 days; COURSE: 3 cycles followed by THERAPY: trastuzumab 6 mg/kg IV Day 1; CYCLE LENGTH: 21 days;
COURSE: 13 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to trastuzumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient must be monitored for one hour after the first dose of trastuzumab. See Emergency Medications.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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ZZtestonc,Andrew [2428787]
11/1/2016 3:31:19 PM Page 35 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
trastuzumab (HERCEPTIN) 476 mg in sodium chloride 0.9 % 250 mL bag
476 mg (rounded from 476.4 mg = 6 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care. See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy. Patient must be
monitored for one hour after the first dose of trastuzumab.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; CHEMOTHERAPY ROOM APPOINTMENT: trastuzumab
for 60 minutes.
Cycle 15 – 7/25/2017 through 8/14/2017 (21 days), Planned
Day 1, Cycle 15 – Planned for 7/25/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Adjuvant); THERAPY: doxorubicin 60 mg/m2 IV Day 1, cyclophosphamide 600 mg/m2 IV Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 14 days; COURSE: 4 cycles followed by THERAPY: trastuzumab 4 mg/kg IV
Day 1, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15, trastuzumab 2 mg/kg IV Days 8 and 15; CYCLE LENGTH: 21 days; COURSE: 1
cycle followed by THERAPY: trastuzumab 2 mg/kg IV Days 1, 8, and 15, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15; CYCLE
LENGTH: 21 days; COURSE: 3 cycles followed by THERAPY: trastuzumab 6 mg/kg IV Day 1; CYCLE LENGTH: 21 days;
COURSE: 13 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/1/2016 3:31:19 PM Page 36 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@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
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to trastuzumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient must be monitored for one hour after the first dose of trastuzumab. See Emergency Medications.
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 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
trastuzumab (HERCEPTIN) 476 mg in sodium chloride 0.9 % 250 mL bag
476 mg (rounded from 476.4 mg = 6 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care. See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy. Patient must be
monitored for one hour after the first dose of trastuzumab.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; CHEMOTHERAPY ROOM APPOINTMENT: trastuzumab
for 60 minutes.
Cycle 16 – 8/15/2017 through 9/4/2017 (21 days), Planned
Day 1, Cycle 16 – Planned for 8/15/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Adjuvant); THERAPY: doxorubicin 60 mg/m2 IV Day 1, cyclophosphamide 600 mg/m2 IV Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 14 days; COURSE: 4 cycles followed by THERAPY: trastuzumab 4 mg/kg IV
Day 1, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15, trastuzumab 2 mg/kg IV Days 8 and 15; CYCLE LENGTH: 21 days; COURSE: 1
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ZZtestonc,Andrew [2428787]
11/1/2016 3:31:19 PM Page 37 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

cycle followed by THERAPY: trastuzumab 2 mg/kg IV Days 1, 8, and 15, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15; CYCLE
LENGTH: 21 days; COURSE: 3 cycles followed by THERAPY: trastuzumab 6 mg/kg IV Day 1; CYCLE LENGTH: 21 days;
COURSE: 13 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to trastuzumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient must be monitored for one hour after the first dose of trastuzumab. See Emergency Medications.
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 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
trastuzumab (HERCEPTIN) 476 mg in sodium chloride 0.9 % 250 mL bag
476 mg (rounded from 476.4 mg = 6 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care. See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy. Patient must be
monitored for one hour after the first dose of trastuzumab.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; CHEMOTHERAPY ROOM APPOINTMENT: trastuzumab
for 60 minutes.
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ZZtestonc,Andrew [2428787]
11/1/2016 3:31:19 PM Page 38 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Cycle 17 – 9/5/2017 through 9/25/2017 (21 days), Planned
Day 1, Cycle 17 – Planned for 9/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Adjuvant); THERAPY: doxorubicin 60 mg/m2 IV Day 1, cyclophosphamide 600 mg/m2 IV Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 14 days; COURSE: 4 cycles followed by THERAPY: trastuzumab 4 mg/kg IV
Day 1, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15, trastuzumab 2 mg/kg IV Days 8 and 15; CYCLE LENGTH: 21 days; COURSE: 1
cycle followed by THERAPY: trastuzumab 2 mg/kg IV Days 1, 8, and 15, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15; CYCLE
LENGTH: 21 days; COURSE: 3 cycles followed by THERAPY: trastuzumab 6 mg/kg IV Day 1; CYCLE LENGTH: 21 days;
COURSE: 13 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to trastuzumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient must be monitored for one hour after the first dose of trastuzumab. See Emergency Medications.
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 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
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ZZtestonc,Andrew [2428787]
11/1/2016 3:31:19 PM Page 39 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

trastuzumab (HERCEPTIN) 476 mg in sodium chloride 0.9 % 250 mL bag
476 mg (rounded from 476.4 mg = 6 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Hypersensitivity risk. For first and second dose, patient should be treated in a location
to optimize emergency care. See emergency medications. Trastuzumab should be given PRIOR to any
chemotherapy. Patient must be monitored for one hour after the first dose of trastuzumab.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; CHEMOTHERAPY ROOM APPOINTMENT: trastuzumab
for 60 minutes.
Cycle 18 – 9/26/2017 through 10/16/2017 (21 days), Planned
Day 1, Cycle 18 – Planned for 9/26/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Adjuvant); THERAPY: doxorubicin 60 mg/m2 IV Day 1, cyclophosphamide 600 mg/m2 IV Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 14 days; COURSE: 4 cycles followed by THERAPY: trastuzumab 4 mg/kg IV
Day 1, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15, trastuzumab 2 mg/kg IV Days 8 and 15; CYCLE LENGTH: 21 days; COURSE: 1
cycle followed by THERAPY: trastuzumab 2 mg/kg IV Days 1, 8, and 15, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15; CYCLE
LENGTH: 21 days; COURSE: 3 cycles followed by THERAPY: trastuzumab 6 mg/kg IV Day 1; CYCLE LENGTH: 21 days;
COURSE: 13 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to trastuzumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient must be monitored for one hour after the first dose of trastuzumab. See Emergency Medications.
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 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
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ZZtestonc,Andrew [2428787]
11/1/2016 3:31:19 PM Page 40 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
trastuzumab (HERCEPTIN) 476 mg in sodium chloride 0.9 % 250 mL bag
476 mg (rounded from 476.4 mg = 6 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care. See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy. Patient must be
monitored for one hour after the first dose of trastuzumab.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; CHEMOTHERAPY ROOM APPOINTMENT: trastuzumab
for 60 minutes.
Cycle 19 – 10/17/2017 through 11/6/2017 (21 days), Planned
Day 1, Cycle 19 – Planned for 10/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Adjuvant); THERAPY: doxorubicin 60 mg/m2 IV Day 1, cyclophosphamide 600 mg/m2 IV Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 14 days; COURSE: 4 cycles followed by THERAPY: trastuzumab 4 mg/kg IV
Day 1, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15, trastuzumab 2 mg/kg IV Days 8 and 15; CYCLE LENGTH: 21 days; COURSE: 1
cycle followed by THERAPY: trastuzumab 2 mg/kg IV Days 1, 8, and 15, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15; CYCLE
LENGTH: 21 days; COURSE: 3 cycles followed by THERAPY: trastuzumab 6 mg/kg IV Day 1; CYCLE LENGTH: 21 days;
COURSE: 13 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to trastuzumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient must be monitored for one hour after the first dose of trastuzumab. See Emergency Medications.
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 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
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ZZtestonc,Andrew [2428787]
11/1/2016 3:31:19 PM Page 41 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
trastuzumab (HERCEPTIN) 476 mg in sodium chloride 0.9 % 250 mL bag
476 mg (rounded from 476.4 mg = 6 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care. See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy. Patient must be
monitored for one hour after the first dose of trastuzumab.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; CHEMOTHERAPY ROOM APPOINTMENT: trastuzumab
for 60 minutes.
Cycle 20 – 11/7/2017 through 11/27/2017 (21 days), Planned
Day 1, Cycle 20 – Planned for 11/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Adjuvant); THERAPY: doxorubicin 60 mg/m2 IV Day 1, cyclophosphamide 600 mg/m2 IV Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 14 days; COURSE: 4 cycles followed by THERAPY: trastuzumab 4 mg/kg IV
Day 1, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15, trastuzumab 2 mg/kg IV Days 8 and 15; CYCLE LENGTH: 21 days; COURSE: 1
cycle followed by THERAPY: trastuzumab 2 mg/kg IV Days 1, 8, and 15, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15; CYCLE
LENGTH: 21 days; COURSE: 3 cycles followed by THERAPY: trastuzumab 6 mg/kg IV Day 1; CYCLE LENGTH: 21 days;
COURSE: 13 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to trastuzumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient must be monitored for one hour after the first dose of trastuzumab. See Emergency Medications.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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ZZtestonc,Andrew [2428787]
11/1/2016 3:31:19 PM Page 42 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
trastuzumab (HERCEPTIN) 476 mg in sodium chloride 0.9 % 250 mL bag
476 mg (rounded from 476.4 mg = 6 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care. See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy. Patient must be
monitored for one hour after the first dose of trastuzumab.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; CHEMOTHERAPY ROOM APPOINTMENT: trastuzumab
for 60 minutes.
Cycle 21 – 11/28/2017 through 12/18/2017 (21 days), Planned
Day 1, Cycle 21 – Planned for 11/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Adjuvant); THERAPY: doxorubicin 60 mg/m2 IV Day 1, cyclophosphamide 600 mg/m2 IV Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 14 days; COURSE: 4 cycles followed by THERAPY: trastuzumab 4 mg/kg IV
Day 1, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15, trastuzumab 2 mg/kg IV Days 8 and 15; CYCLE LENGTH: 21 days; COURSE: 1
cycle followed by THERAPY: trastuzumab 2 mg/kg IV Days 1, 8, and 15, PACLItaxel 80 mg/m2 IV Days 1, 8, and 15; CYCLE
LENGTH: 21 days; COURSE: 3 cycles followed by THERAPY: trastuzumab 6 mg/kg IV Day 1; CYCLE LENGTH: 21 days;
COURSE: 13 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/1/2016 3:31:19 PM Page 43 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@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
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to trastuzumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient must be monitored for one hour after the first dose of trastuzumab. See Emergency Medications.
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 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
trastuzumab (HERCEPTIN) 476 mg in sodium chloride 0.9 % 250 mL bag
476 mg (rounded from 476.4 mg = 6 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care. See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy. Patient must be
monitored for one hour after the first dose of trastuzumab.
Follow-Up
DAY 90 FOLLOW-UP
(3 Month Follow-Up) RETURN TO CLINIC for appointment with provider.
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ZZtestonc,Andrew [2428787]
11/1/2016 3:31:19 PM Page 44 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org