/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-96595-en.cckm

201710275

page

100

UWHC,UWMF,

Tools,

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

CSC Breast C1-6:Carboplatin(21D:1)/Docetaxel(21D:1)/Pertuzumab(21D:1)/Trastuzumab(21D:1) Followed by C7-17: Trastuzumab(21D:1) VER 9-29-17 (HL 5329)

CSC Breast C1-6:Carboplatin(21D:1)/Docetaxel(21D:1)/Pertuzumab(21D:1)/Trastuzumab(21D:1) Followed by C7-17: Trastuzumab(21D:1) VER 9-29-17 (HL 5329) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Breast


CSC BREAST C1-6:CARBOPLATIN(21D:1)/DOCETAXEL(21D:1)/PERTUZUMAB(21D:1)/TRASTUZUMAB(21D:1)
FOLLOWED BY C7-17:TRASTUZUMAB(21D:1) VER: 9-29-17 –  Properties
Pre-Cycle –  9/22/2017 through 9/28/2017 (7 days), Planned
Day 1, Pre-Cycle –  Planned for 9/22/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Neoadjuvant/ Adjuvant); THERAPY: pertuzumab 840 mg IV Day 1, trastuzumab 8 mg/kg IV Day
1, DOCEtaxel 75 mg/m2 IV Day 1, CARBOplatin (AUC = 6) IV Day 1; CYCLE LENGTH: 21 days; COURSE: 1 cycle followed
by THERAPY: pertuzumab 420 mg IV Day 1, trastuzumab 6 mg/kg IV Day 1, DOCEtaxel 75 mg/m2 IV Day 1,
CARBOplatin (AUC = 6) IV Day 1; CYCLE LENGTH: 21 days; COURSE: 5 cycles followed by THERAPY: trastuzumab 6
mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE 11 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
ALT/SGPT
Expected: S Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S Approximate, Expires: S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE
Expected: S Approximate, Expires: S+365, Routine
Treatment Conditions
Treatment Condition A
Verify patient has obtained pretreatment MUGA or ECHO.
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
Take 2 tabs by mouth 2 times daily. Take for 3 days, starting AM on the day prior to DOCEtaxel., 8 mg, Disp-36 tab,
R-1, 2 X DAILY starting S
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth twice daily X 2 days after chemo then 1 tab every 8h as needed for nausea., Disp-30 tab, R-5,
starting S
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
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Zztestonc,Fiona F [2462287]
9/29/2017 1:08:18 PM Page 1 of 30
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Cycle 1 –  9/29/2017 through 10/19/2017 (21 days), Planned
Day 1, Cycle 1 –  Planned for 9/29/2017
Treatment Plan Information
Reference Information (1)
BREAST CANCER: Swain S, et al. Lancet Oncol 2013;14(6):461-71.
Reference Information (2)
BREAST CANCER: Gianni L, et al. Lancet Oncol 2012;13(1):25-32.
Reference Information (3)
BREAST CANCER: Untch M, et al. J Clin Oncol 2011;29(25):3351-7.
Reference Information (4)
BREAST CANCER: Schneeweiss A, et al. Ann Oncol 2013;24(9):2278-84.
Treatment Plan Summary
DISEASE: Breast Cancer (Neoadjuvant/ Adjuvant); THERAPY: pertuzumab 840 mg IV Day 1, trastuzumab 8 mg/kg IV Day
1, DOCEtaxel 75 mg/m2 IV Day 1, CARBOplatin (AUC = 6) IV Day 1; CYCLE LENGTH: 21 days; COURSE: 1 cycle followed
by THERAPY: pertuzumab 420 mg IV Day 1, trastuzumab 6 mg/kg IV Day 1, DOCEtaxel 75 mg/m2 IV Day 1,
CARBOplatin (AUC = 6) IV Day 1; CYCLE LENGTH: 21 days; COURSE: 5 cycles followed by THERAPY: trastuzumab 6
mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE 11 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 1,000/µL or Platelets less than or equal to 100K/µL or
Creatinine greater than ULN or AST greater than 1.5 X ULN or Total Bilirubin greater than ULN.
Treatment Condition A
Verify patient has obtained pretreatment MUGA or ECHO.
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 to pertuzumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications. Patient should be monitored for 30 minutes after the first dose of
pertuzumab.
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
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Zztestonc,Fiona F [2462287]
9/29/2017 1:08:18 PM Page 2 of 30
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Hypersensitivity Monitoring (2)
Hypersensitivity reaction to trastuzumab can occur.  For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications. Patient must be monitored for one hour after the first dose of
trastuzumab.
Hypersensitivity Monitoring (3)
Hypersensitivity to DOCEtaxel can occur.  For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Hypersensitivity Monitoring (4)
Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. 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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN Starting when released Until Discontinued, If PO not taken at home.
For use in patients who did not take dexamethasone at home.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Emergency Medications
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 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
pertuzumab (PERJETA) 840 mg in sodium chloride 0.9 % 250 mL bag
840 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes. Hypersensitivity can occur. For first and second dose patient should be treated in a
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Zztestonc,Fiona F [2462287]
9/29/2017 1:08:18 PM Page 3 of 30
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

location to optimize emergency care. See Emergency Medications. Do NOT administer by rapid push or bolus. Patient
must be monitored for 30 minutes after the first dose of pertuzumab. No additional medications to be administered
during observation period.
trastuzumab (HERCEPTIN) 8 mg/kg in sodium chloride 0.9 % 250 mL bag
8 mg/kg, Intravenous, ONCE, 1 dose Starting when released, Administer over 90 Minutes
Give first dose over 90 minutes and subsequent doses over 30 minutes. Hypersensitivity risk. For first and second dose,
patient should be treated in a location to optimize emergency care. See Emergency Medications. Patient must be
monitored for one hour after the first dose of trastuzumab. Trastuzumab should be given prior to any chemotherapy.
DOCEtaxel (TAXOTERE) 75 mg/m2 in dextrose 5 % 100 mL non-PVC bag
75 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes. Hypersensitivity risk. See emergency medications. In non-PVC bag. Infuse through non PVC
tubing.
1st dose or if patient reacted to previous dose:
50 mL/hr for 3 to 5 min,
100 mL/hr for 3 to 5 min,
150 mL/hr for 3 to 5 min,
then max rate for remainder. RN to remain at bedside for additional 3 to 5 minutes.
If patient did not react to 1st or subsequent doses, administer volume of bag over ordered duration.
CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
(Target AUC = 6), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Hypersensitivity risk. See Emergency Medications.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Creatinine, ALT, AST, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: pertuzumab, trastuzumab, DOCEtaxel,
and CARBOplatin for 240 minutes.
Cycle 2 –  10/20/2017 through 11/9/2017 (21 days), Planned
Day 1, Cycle 2 –  Planned for 10/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Neoadjuvant/ Adjuvant); THERAPY: pertuzumab 840 mg IV Day 1, trastuzumab 8 mg/kg IV Day
1, DOCEtaxel 75 mg/m2 IV Day 1, CARBOplatin (AUC = 6) IV Day 1; CYCLE LENGTH: 21 days; COURSE: 1 cycle followed
by THERAPY: pertuzumab 420 mg IV Day 1, trastuzumab 6 mg/kg IV Day 1, DOCEtaxel 75 mg/m2 IV Day 1,
CARBOplatin (AUC = 6) IV Day 1; CYCLE LENGTH: 21 days; COURSE: 5 cycles followed by THERAPY: trastuzumab 6
mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE 11 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+21 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+21 Approximate, Expires: S+365, Routine
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Zztestonc,Fiona F [2462287]
9/29/2017 1:08:18 PM Page 4 of 30
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

CREATININE
Expected: S+21 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+21 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+21 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+21 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 1,000/µL or Platelets less than or equal to 100K/µL or
Creatinine greater than ULN or AST greater than 1.5 X ULN or Total Bilirubin greater than 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 to pertuzumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications. Patient should be monitored for 30 minutes after the first dose of
pertuzumab.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to trastuzumab can occur.  For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications. Patient must be monitored for one hour after the first dose of
trastuzumab.
Hypersensitivity Monitoring (3)
Hypersensitivity to DOCEtaxel can occur.  For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Hypersensitivity Monitoring (4)
Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. 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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
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Zztestonc,Fiona F [2462287]
9/29/2017 1:08:18 PM Page 5 of 30
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Emergency Medications
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 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
pertuzumab (PERJETA) 420 mg in sodium chloride 0.9 % 250 mL bag
420 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Hypersensitivity can occur. For first and second dose patient should be treated in a
location to optimize emergency care. See emergency medications. Do NOT administer by rapid push or bolus.
trastuzumab (HERCEPTIN) 6 mg/kg in sodium chloride 0.9 % 250 mL bag
6 mg/kg, Intravenous, ONCE, 1 dose Starting when released, Administer over 30 Minutes
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.
DOCEtaxel (TAXOTERE) 75 mg/m2 in dextrose 5 % 100 mL non-PVC bag
75 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes. Hypersensitivity risk. See emergency medications. In non-PVC bag. Infuse through non PVC
tubing.
1st dose or if patient reacted to previous dose:
50 mL/hr for 3 to 5 min,
100 mL/hr for 3 to 5 min,
150 mL/hr for 3 to 5 min,
then max rate for remainder. RN to remain at bedside for additional 3 to 5 minutes.
If patient did not react to 1st or subsequent doses, administer volume of bag over ordered duration.
CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
(Target AUC = 6), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Hypersensitivity risk. See Emergency Medications.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Creatinine, ALT, AST, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: pertuzumab, trastuzumab, DOCEtaxel,
and CARBOplatin for 240 minutes.
Cycle 3 –  11/10/2017 through 11/30/2017 (21 days), Planned
Day 1, Cycle 3 –  Planned for 11/10/2017
Treatment Plan Information
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Zztestonc,Fiona F [2462287]
9/29/2017 1:08:18 PM Page 6 of 30
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Breast Cancer (Neoadjuvant/ Adjuvant); THERAPY: pertuzumab 840 mg IV Day 1, trastuzumab 8 mg/kg IV Day
1, DOCEtaxel 75 mg/m2 IV Day 1, CARBOplatin (AUC = 6) IV Day 1; CYCLE LENGTH: 21 days; COURSE: 1 cycle followed
by THERAPY: pertuzumab 420 mg IV Day 1, trastuzumab 6 mg/kg IV Day 1, DOCEtaxel 75 mg/m2 IV Day 1,
CARBOplatin (AUC = 6) IV Day 1; CYCLE LENGTH: 21 days; COURSE: 5 cycles followed by THERAPY: trastuzumab 6
mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE 11 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+21 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+21 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+21 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+21 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+21 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+21 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 1,000/µL or Platelets less than or equal to 100K/µL or
Creatinine greater than ULN or AST greater than 1.5 X ULN or Total Bilirubin greater than 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 to pertuzumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications. Patient should be monitored for 30 minutes after the first dose of
pertuzumab.
Hypersensitivity Monitoring (2)
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Zztestonc,Fiona F [2462287]
9/29/2017 1:08:18 PM Page 7 of 30
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Hypersensitivity reaction to trastuzumab can occur.  For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications. Patient must be monitored for one hour after the first dose of
trastuzumab.
Hypersensitivity Monitoring (3)
Hypersensitivity to DOCEtaxel can occur.  For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Hypersensitivity Monitoring (4)
Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. 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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Emergency Medications
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 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
pertuzumab (PERJETA) 420 mg in sodium chloride 0.9 % 250 mL bag
420 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Hypersensitivity can occur. For first and second dose patient should be treated in a
location to optimize emergency care. See emergency medications. Do NOT administer by rapid push or bolus.
trastuzumab (HERCEPTIN) 6 mg/kg in sodium chloride 0.9 % 250 mL bag
6 mg/kg, Intravenous, ONCE, 1 dose Starting when released, Administer over 30 Minutes
Administer over 30 minutes. Hypersensitivity risk. For first and second dose, patient should be treated in a location to
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Zztestonc,Fiona F [2462287]
9/29/2017 1:08:18 PM Page 8 of 30
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

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.
DOCEtaxel (TAXOTERE) 75 mg/m2 in dextrose 5 % 100 mL non-PVC bag
75 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes. Hypersensitivity risk. See emergency medications. In non-PVC bag. Infuse through non PVC
tubing.
1st dose or if patient reacted to previous dose:
50 mL/hr for 3 to 5 min,
100 mL/hr for 3 to 5 min,
150 mL/hr for 3 to 5 min,
then max rate for remainder. RN to remain at bedside for additional 3 to 5 minutes.
If patient did not react to 1st or subsequent doses, administer volume of bag over ordered duration.
CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
(Target AUC = 6), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Hypersensitivity risk. See Emergency Medications.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Creatinine, ALT, AST, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: pertuzumab, trastuzumab, DOCEtaxel,
and CARBOplatin for 240 minutes.
Cycle 4 –  12/1/2017 through 12/21/2017 (21 days), Planned
Day 1, Cycle 4 –  Planned for 12/1/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Neoadjuvant/ Adjuvant); THERAPY: pertuzumab 840 mg IV Day 1, trastuzumab 8 mg/kg IV Day
1, DOCEtaxel 75 mg/m2 IV Day 1, CARBOplatin (AUC = 6) IV Day 1; CYCLE LENGTH: 21 days; COURSE: 1 cycle followed
by THERAPY: pertuzumab 420 mg IV Day 1, trastuzumab 6 mg/kg IV Day 1, DOCEtaxel 75 mg/m2 IV Day 1,
CARBOplatin (AUC = 6) IV Day 1; CYCLE LENGTH: 21 days; COURSE: 5 cycles followed by THERAPY: trastuzumab 6
mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE 11 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+21 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+21 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+21 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+21 Approximate, Expires: S+365, Routine
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Zztestonc,Fiona F [2462287]
9/29/2017 1:08:18 PM Page 9 of 30
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

AST/SGOT
Expected: S+21 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+21 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 1,000/µL or Platelets less than or equal to 100K/µL or
Creatinine greater than ULN or AST greater than 1.5 X ULN or Total Bilirubin greater than 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 to pertuzumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications. Patient should be monitored for 30 minutes after the first dose of
pertuzumab.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to trastuzumab can occur.  For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications. Patient must be monitored for one hour after the first dose of
trastuzumab.
Hypersensitivity Monitoring (3)
Hypersensitivity to DOCEtaxel can occur.  For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Hypersensitivity Monitoring (4)
Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. 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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
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Zztestonc,Fiona F [2462287]
9/29/2017 1:08:18 PM Page 10 of 30
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Emergency Medications
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 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
pertuzumab (PERJETA) 420 mg in sodium chloride 0.9 % 250 mL bag
420 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Hypersensitivity can occur. For first and second dose patient should be treated in a
location to optimize emergency care. See emergency medications. Do NOT administer by rapid push or bolus.
trastuzumab (HERCEPTIN) 6 mg/kg in sodium chloride 0.9 % 250 mL bag
6 mg/kg, Intravenous, ONCE, 1 dose Starting when released, Administer over 30 Minutes
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.
DOCEtaxel (TAXOTERE) 75 mg/m2 in dextrose 5 % 100 mL non-PVC bag
75 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes. Hypersensitivity risk. See emergency medications. In non-PVC bag. Infuse through non PVC
tubing.
1st dose or if patient reacted to previous dose:
50 mL/hr for 3 to 5 min,
100 mL/hr for 3 to 5 min,
150 mL/hr for 3 to 5 min,
then max rate for remainder. RN to remain at bedside for additional 3 to 5 minutes.
If patient did not react to 1st or subsequent doses, administer volume of bag over ordered duration.
CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
(Target AUC = 6), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Hypersensitivity risk. See Emergency Medications.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Creatinine, ALT, AST, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: pertuzumab, trastuzumab, DOCEtaxel,
and CARBOplatin for 240 minutes.
Cycle 5 –  12/22/2017 through 1/11/2018 (21 days), Planned
Day 1, Cycle 5 –  Planned for 12/22/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Neoadjuvant/ Adjuvant); THERAPY: pertuzumab 840 mg IV Day 1, trastuzumab 8 mg/kg IV Day
1, DOCEtaxel 75 mg/m2 IV Day 1, CARBOplatin (AUC = 6) IV Day 1; CYCLE LENGTH: 21 days; COURSE: 1 cycle followed
by THERAPY: pertuzumab 420 mg IV Day 1, trastuzumab 6 mg/kg IV Day 1, DOCEtaxel 75 mg/m2 IV Day 1,
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Zztestonc,Fiona F [2462287]
9/29/2017 1:08:18 PM Page 11 of 30
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

CARBOplatin (AUC = 6) IV Day 1; CYCLE LENGTH: 21 days; COURSE: 5 cycles followed by THERAPY: trastuzumab 6
mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE 11 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+21 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+21 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+21 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+21 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+21 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+21 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 1,000/µL or Platelets less than or equal to 100K/µL or
Creatinine greater than ULN or AST greater than 1.5 X ULN or Total Bilirubin greater than 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 to pertuzumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications. Patient should be monitored for 30 minutes after the first dose of
pertuzumab.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to trastuzumab can occur.  For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications. Patient must be monitored for one hour after the first dose of
trastuzumab.
Hypersensitivity Monitoring (3)
Hypersensitivity to DOCEtaxel can occur.  For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Hypersensitivity Monitoring (4)
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Zztestonc,Fiona F [2462287]
9/29/2017 1:08:18 PM Page 12 of 30
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient should be
treated in a location to optimize emergency care. 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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Emergency Medications
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 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
pertuzumab (PERJETA) 420 mg in sodium chloride 0.9 % 250 mL bag
420 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Hypersensitivity can occur. For first and second dose patient should be treated in a
location to optimize emergency care. See emergency medications. Do NOT administer by rapid push or bolus.
trastuzumab (HERCEPTIN) 6 mg/kg in sodium chloride 0.9 % 250 mL bag
6 mg/kg, Intravenous, ONCE, 1 dose Starting when released, Administer over 30 Minutes
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.
DOCEtaxel (TAXOTERE) 75 mg/m2 in dextrose 5 % 100 mL non-PVC bag
75 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes. Hypersensitivity risk. See emergency medications. In non-PVC bag. Infuse through non PVC
tubing.
1st dose or if patient reacted to previous dose:
50 mL/hr for 3 to 5 min,
100 mL/hr for 3 to 5 min,
150 mL/hr for 3 to 5 min,
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Zztestonc,Fiona F [2462287]
9/29/2017 1:08:18 PM Page 13 of 30
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

then max rate for remainder. RN to remain at bedside for additional 3 to 5 minutes.
If patient did not react to 1st or subsequent doses, administer volume of bag over ordered duration.
CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
(Target AUC = 6), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Hypersensitivity risk. See Emergency Medications.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Creatinine, ALT, AST, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: pertuzumab, trastuzumab, DOCEtaxel,
and CARBOplatin for 240 minutes.
Cycle 6 –  1/12/2018 through 2/1/2018 (21 days), Planned
Day 1, Cycle 6 –  Planned for 1/12/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Neoadjuvant/ Adjuvant); THERAPY: pertuzumab 840 mg IV Day 1, trastuzumab 8 mg/kg IV Day
1, DOCEtaxel 75 mg/m2 IV Day 1, CARBOplatin (AUC = 6) IV Day 1; CYCLE LENGTH: 21 days; COURSE: 1 cycle followed
by THERAPY: pertuzumab 420 mg IV Day 1, trastuzumab 6 mg/kg IV Day 1, DOCEtaxel 75 mg/m2 IV Day 1,
CARBOplatin (AUC = 6) IV Day 1; CYCLE LENGTH: 21 days; COURSE: 5 cycles followed by THERAPY: trastuzumab 6
mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE 11 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+21 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+21 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+21 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+21 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+21 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+21 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
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Zztestonc,Fiona F [2462287]
9/29/2017 1:08:18 PM Page 14 of 30
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than or equal to 100K/µL or
Creatinine greater than ULN or AST greater than 1.5 X ULN or Total Bilirubin greater than 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 to pertuzumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications. Patient should be monitored for 30 minutes after the first dose of
pertuzumab.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to trastuzumab can occur.  For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications. Patient must be monitored for one hour after the first dose of
trastuzumab.
Hypersensitivity Monitoring (3)
Hypersensitivity to DOCEtaxel can occur.  For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Hypersensitivity Monitoring (4)
Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. 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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Emergency Medications
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 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
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Zztestonc,Fiona F [2462287]
9/29/2017 1:08:18 PM Page 15 of 30
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
pertuzumab (PERJETA) 420 mg in sodium chloride 0.9 % 250 mL bag
420 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Hypersensitivity can occur. For first and second dose patient should be treated in a
location to optimize emergency care. See emergency medications. Do NOT administer by rapid push or bolus.
trastuzumab (HERCEPTIN) 6 mg/kg in sodium chloride 0.9 % 250 mL bag
6 mg/kg, Intravenous, ONCE, 1 dose Starting when released, Administer over 30 Minutes
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.
DOCEtaxel (TAXOTERE) 75 mg/m2 in dextrose 5 % 100 mL non-PVC bag
75 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes. Hypersensitivity risk. See emergency medications. In non-PVC bag. Infuse through non PVC
tubing.
1st dose or if patient reacted to previous dose:
50 mL/hr for 3 to 5 min,
100 mL/hr for 3 to 5 min,
150 mL/hr for 3 to 5 min,
then max rate for remainder. RN to remain at bedside for additional 3 to 5 minutes.
If patient did not react to 1st or subsequent doses, administer volume of bag over ordered duration.
CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
(Target AUC = 6), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Hypersensitivity risk. See Emergency Medications.
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 7 –  2/2/2018 through 2/22/2018 (21 days), Planned
Day 1, Cycle 7 –  Planned for 2/2/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Neoadjuvant/ Adjuvant); THERAPY: pertuzumab 840 mg IV Day 1, trastuzumab 8 mg/kg IV Day
1, DOCEtaxel 75 mg/m2 IV Day 1, CARBOplatin (AUC = 6) IV Day 1; CYCLE LENGTH: 21 days; COURSE: 1 cycle followed
by THERAPY: pertuzumab 420 mg IV Day 1, trastuzumab 6 mg/kg IV Day 1, DOCEtaxel 75 mg/m2 IV Day 1,
CARBOplatin (AUC = 6) IV Day 1; CYCLE LENGTH: 21 days; COURSE: 5 cycles followed by THERAPY: trastuzumab 6
mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE 11 cycles
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Fiona F [2462287]
9/29/2017 1:08:18 PM Page 16 of 30
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Emergency Medications
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 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
trastuzumab (HERCEPTIN) 6 mg/kg in sodium chloride 0.9 % 250 mL bag
6 mg/kg, Intravenous, ONCE, 1 dose Starting when released, Administer over 30 Minutes
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 8 –  2/23/2018 through 3/15/2018 (21 days), Planned
Day 1, Cycle 8 –  Planned for 2/23/2018
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Zztestonc,Fiona F [2462287]
9/29/2017 1:08:18 PM Page 17 of 30
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Neoadjuvant/ Adjuvant); THERAPY: pertuzumab 840 mg IV Day 1, trastuzumab 8 mg/kg IV Day
1, DOCEtaxel 75 mg/m2 IV Day 1, CARBOplatin (AUC = 6) IV Day 1; CYCLE LENGTH: 21 days; COURSE: 1 cycle followed
by THERAPY: pertuzumab 420 mg IV Day 1, trastuzumab 6 mg/kg IV Day 1, DOCEtaxel 75 mg/m2 IV Day 1,
CARBOplatin (AUC = 6) IV Day 1; CYCLE LENGTH: 21 days; COURSE: 5 cycles followed by THERAPY: trastuzumab 6
mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE 11 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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Emergency Medications
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 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
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,Fiona F [2462287]
9/29/2017 1:08:18 PM Page 18 of 30
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Treatment Medications
trastuzumab (HERCEPTIN) 6 mg/kg in sodium chloride 0.9 % 250 mL bag
6 mg/kg, Intravenous, ONCE, 1 dose Starting when released, Administer over 30 Minutes
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 9 –  3/16/2018 through 4/5/2018 (21 days), Planned
Day 1, Cycle 9 –  Planned for 3/16/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Neoadjuvant/ Adjuvant); THERAPY: pertuzumab 840 mg IV Day 1, trastuzumab 8 mg/kg IV Day
1, DOCEtaxel 75 mg/m2 IV Day 1, CARBOplatin (AUC = 6) IV Day 1; CYCLE LENGTH: 21 days; COURSE: 1 cycle followed
by THERAPY: pertuzumab 420 mg IV Day 1, trastuzumab 6 mg/kg IV Day 1, DOCEtaxel 75 mg/m2 IV Day 1,
CARBOplatin (AUC = 6) IV Day 1; CYCLE LENGTH: 21 days; COURSE: 5 cycles followed by THERAPY: trastuzumab 6
mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE 11 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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
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Zztestonc,Fiona F [2462287]
9/29/2017 1:08:18 PM Page 19 of 30
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Emergency Medications
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 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
trastuzumab (HERCEPTIN) 6 mg/kg in sodium chloride 0.9 % 250 mL bag
6 mg/kg, Intravenous, ONCE, 1 dose Starting when released, Administer over 30 Minutes
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 –  4/6/2018 through 4/26/2018 (21 days), Planned
Day 1, Cycle 10 –  Planned for 4/6/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Neoadjuvant/ Adjuvant); THERAPY: pertuzumab 840 mg IV Day 1, trastuzumab 8 mg/kg IV Day
1, DOCEtaxel 75 mg/m2 IV Day 1, CARBOplatin (AUC = 6) IV Day 1; CYCLE LENGTH: 21 days; COURSE: 1 cycle followed
by THERAPY: pertuzumab 420 mg IV Day 1, trastuzumab 6 mg/kg IV Day 1, DOCEtaxel 75 mg/m2 IV Day 1,
CARBOplatin (AUC = 6) IV Day 1; CYCLE LENGTH: 21 days; COURSE: 5 cycles followed by THERAPY: trastuzumab 6
mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE 11 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)
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Zztestonc,Fiona F [2462287]
9/29/2017 1:08:18 PM Page 20 of 30
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@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.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Emergency Medications
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 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
trastuzumab (HERCEPTIN) 6 mg/kg in sodium chloride 0.9 % 250 mL bag
6 mg/kg, Intravenous, ONCE, 1 dose Starting when released, Administer over 30 Minutes
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 11 –  4/27/2018 through 5/17/2018 (21 days), Planned
Day 1, Cycle 11 –  Planned for 4/27/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Neoadjuvant/ Adjuvant); THERAPY: pertuzumab 840 mg IV Day 1, trastuzumab 8 mg/kg IV Day
1, DOCEtaxel 75 mg/m2 IV Day 1, CARBOplatin (AUC = 6) IV Day 1; CYCLE LENGTH: 21 days; COURSE: 1 cycle followed
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Zztestonc,Fiona F [2462287]
9/29/2017 1:08:18 PM Page 21 of 30
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

by THERAPY: pertuzumab 420 mg IV Day 1, trastuzumab 6 mg/kg IV Day 1, DOCEtaxel 75 mg/m2 IV Day 1,
CARBOplatin (AUC = 6) IV Day 1; CYCLE LENGTH: 21 days; COURSE: 5 cycles followed by THERAPY: trastuzumab 6
mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE 11 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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Emergency Medications
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 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
trastuzumab (HERCEPTIN) 6 mg/kg in sodium chloride 0.9 % 250 mL bag
6 mg/kg, Intravenous, ONCE, 1 dose Starting when released, Administer over 30 Minutes
Administer over 30 minutes. Hypersensitivity risk. For first and second dose, patient should be treated in a location to
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Zztestonc,Fiona F [2462287]
9/29/2017 1:08:18 PM Page 22 of 30
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

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 –  5/18/2018 through 6/7/2018 (21 days), Planned
Day 1, Cycle 12 –  Planned for 5/18/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Neoadjuvant/ Adjuvant); THERAPY: pertuzumab 840 mg IV Day 1, trastuzumab 8 mg/kg IV Day
1, DOCEtaxel 75 mg/m2 IV Day 1, CARBOplatin (AUC = 6) IV Day 1; CYCLE LENGTH: 21 days; COURSE: 1 cycle followed
by THERAPY: pertuzumab 420 mg IV Day 1, trastuzumab 6 mg/kg IV Day 1, DOCEtaxel 75 mg/m2 IV Day 1,
CARBOplatin (AUC = 6) IV Day 1; CYCLE LENGTH: 21 days; COURSE: 5 cycles followed by THERAPY: trastuzumab 6
mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE 11 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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Emergency Medications
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Zztestonc,Fiona F [2462287]
9/29/2017 1:08:18 PM Page 23 of 30
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

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 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
trastuzumab (HERCEPTIN) 6 mg/kg in sodium chloride 0.9 % 250 mL bag
6 mg/kg, Intravenous, ONCE, 1 dose Starting when released, Administer over 30 Minutes
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 –  6/8/2018 through 6/28/2018 (21 days), Planned
Day 1, Cycle 13 –  Planned for 6/8/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Neoadjuvant/ Adjuvant); THERAPY: pertuzumab 840 mg IV Day 1, trastuzumab 8 mg/kg IV Day
1, DOCEtaxel 75 mg/m2 IV Day 1, CARBOplatin (AUC = 6) IV Day 1; CYCLE LENGTH: 21 days; COURSE: 1 cycle followed
by THERAPY: pertuzumab 420 mg IV Day 1, trastuzumab 6 mg/kg IV Day 1, DOCEtaxel 75 mg/m2 IV Day 1,
CARBOplatin (AUC = 6) IV Day 1; CYCLE LENGTH: 21 days; COURSE: 5 cycles followed by THERAPY: trastuzumab 6
mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE 11 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,Fiona F [2462287]
9/29/2017 1:08:18 PM Page 24 of 30
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Emergency Medications
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 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
trastuzumab (HERCEPTIN) 6 mg/kg in sodium chloride 0.9 % 250 mL bag
6 mg/kg, Intravenous, ONCE, 1 dose Starting when released, Administer over 30 Minutes
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 –  6/29/2018 through 7/19/2018 (21 days), Planned
Day 1, Cycle 14 –  Planned for 6/29/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Neoadjuvant/ Adjuvant); THERAPY: pertuzumab 840 mg IV Day 1, trastuzumab 8 mg/kg IV Day
1, DOCEtaxel 75 mg/m2 IV Day 1, CARBOplatin (AUC = 6) IV Day 1; CYCLE LENGTH: 21 days; COURSE: 1 cycle followed
by THERAPY: pertuzumab 420 mg IV Day 1, trastuzumab 6 mg/kg IV Day 1, DOCEtaxel 75 mg/m2 IV Day 1,
CARBOplatin (AUC = 6) IV Day 1; CYCLE LENGTH: 21 days; COURSE: 5 cycles followed by THERAPY: trastuzumab 6
mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE 11 cycles
Consent
Verify Consent
Verify informed consent has been obtained.
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Zztestonc,Fiona F [2462287]
9/29/2017 1:08:18 PM Page 25 of 30
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Emergency Medications
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 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
trastuzumab (HERCEPTIN) 6 mg/kg in sodium chloride 0.9 % 250 mL bag
6 mg/kg, Intravenous, ONCE, 1 dose Starting when released, Administer over 30 Minutes
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,Fiona F [2462287]
9/29/2017 1:08:18 PM Page 26 of 30
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Cycle 15 –  7/20/2018 through 8/9/2018 (21 days), Planned
Day 1, Cycle 15 –  Planned for 7/20/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Neoadjuvant/ Adjuvant); THERAPY: pertuzumab 840 mg IV Day 1, trastuzumab 8 mg/kg IV Day
1, DOCEtaxel 75 mg/m2 IV Day 1, CARBOplatin (AUC = 6) IV Day 1; CYCLE LENGTH: 21 days; COURSE: 1 cycle followed
by THERAPY: pertuzumab 420 mg IV Day 1, trastuzumab 6 mg/kg IV Day 1, DOCEtaxel 75 mg/m2 IV Day 1,
CARBOplatin (AUC = 6) IV Day 1; CYCLE LENGTH: 21 days; COURSE: 5 cycles followed by THERAPY: trastuzumab 6
mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE 11 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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Emergency Medications
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 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
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Zztestonc,Fiona F [2462287]
9/29/2017 1:08:18 PM Page 27 of 30
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@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) 6 mg/kg in sodium chloride 0.9 % 250 mL bag
6 mg/kg, Intravenous, ONCE, 1 dose Starting when released, Administer over 30 Minutes
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 –  8/10/2018 through 8/30/2018 (21 days), Planned
Day 1, Cycle 16 –  Planned for 8/10/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Neoadjuvant/ Adjuvant); THERAPY: pertuzumab 840 mg IV Day 1, trastuzumab 8 mg/kg IV Day
1, DOCEtaxel 75 mg/m2 IV Day 1, CARBOplatin (AUC = 6) IV Day 1; CYCLE LENGTH: 21 days; COURSE: 1 cycle followed
by THERAPY: pertuzumab 420 mg IV Day 1, trastuzumab 6 mg/kg IV Day 1, DOCEtaxel 75 mg/m2 IV Day 1,
CARBOplatin (AUC = 6) IV Day 1; CYCLE LENGTH: 21 days; COURSE: 5 cycles followed by THERAPY: trastuzumab 6
mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE 11 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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
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Zztestonc,Fiona F [2462287]
9/29/2017 1:08:18 PM Page 28 of 30
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Emergency Medications
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 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
trastuzumab (HERCEPTIN) 6 mg/kg in sodium chloride 0.9 % 250 mL bag
6 mg/kg, Intravenous, ONCE, 1 dose Starting when released, Administer over 30 Minutes
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 17 –  8/31/2018 through 9/20/2018 (21 days), Planned
Day 1, Cycle 17 –  Planned for 8/31/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Neoadjuvant/ Adjuvant); THERAPY: pertuzumab 840 mg IV Day 1, trastuzumab 8 mg/kg IV Day
1, DOCEtaxel 75 mg/m2 IV Day 1, CARBOplatin (AUC = 6) IV Day 1; CYCLE LENGTH: 21 days; COURSE: 1 cycle followed
by THERAPY: pertuzumab 420 mg IV Day 1, trastuzumab 6 mg/kg IV Day 1, DOCEtaxel 75 mg/m2 IV Day 1,
CARBOplatin (AUC = 6) IV Day 1; CYCLE LENGTH: 21 days; COURSE: 5 cycles followed by THERAPY: trastuzumab 6
mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE 11 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)
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Zztestonc,Fiona F [2462287]
9/29/2017 1:08:18 PM Page 29 of 30
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@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.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Emergency Medications
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 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
trastuzumab (HERCEPTIN) 6 mg/kg in sodium chloride 0.9 % 250 mL bag
6 mg/kg, Intravenous, ONCE, 1 dose Starting when released, Administer over 30 Minutes
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
MULTIPLE DAY FOLLOW-UP (1)
Care Planning for: {UWONC SURVIVORSHIP PLANNING:7700070}
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Zztestonc,Fiona F [2462287]
9/29/2017 1:08:18 PM Page 30 of 30
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org