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

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201611306

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CSC Breast Cyclophosphamide (14D1), Doxorubicin (14D1) PACLItaxel (14D1) VER 10-3-16 (HL 674)

CSC Breast Cyclophosphamide (14D1), Doxorubicin (14D1) PACLItaxel (14D1) VER 10-3-16 (HL 674) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Breast


CSC BREAST CYCLOPHOSPHAMIDE(14D:1)DOXORUBICIN(14D:1)+PACLITAXEL(14D: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.
May be followed by: THERAPY: PACLItaxel 175 mg/m2 IV Day 1; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 14 days;
COURSE: 4 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-5, 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-5, 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-5, EVERY 8 HOURS PRN starting S, Local Printer
Take Home Medications (delete all that do not apply)
TBO-filgrastim (GRANIX) 300 MCG/0.5ML soln prefilled syringe
Inject 300 mcg under skin one time daily in evening. Begin Day ***. Continue until ANC is greater than *** after nadir., 300 mcg,
Disp-10 Syringe, R-5, 1 X DAILY (PM) starting S, Local Printer
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
TBO-filgrastim (GRANIX) 480 MCG/0.8ML soln prefilled syringe
Inject 480 mcg under skin one time daily in evening. Begin Day ***. Continue until ANC is greater than *** after nadir., 480 mcg,
Disp-10 Syringe, R-5, 1 X DAILY (PM) starting S, Local Printer
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
Cycle 1 – 11/1/2016 through 11/14/2016 (14 days), Planned
Day 1, Cycle 1 – Planned for 11/1/2016
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ZZtestonc,Andrew [2428787]
11/1/2016 3:36:03 PM Page 1 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Plan Information
Reference Information (1)
BREAST CANCER: Citron ML, et al. J Clin Oncol 2003;21:1431-39.
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.
May be followed by: THERAPY: PACLItaxel 175 mg/m2 IV Day 1; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 14 days;
COURSE: 4 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, 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 Total Bilirubin greater than 1.2 mg/dL or AST greater than 1.5X ULN.
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.
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
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ZZtestonc,Andrew [2428787]
11/1/2016 3:36:03 PM Page 2 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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,
Total Bilirubin, AST; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, cyclophosphamide for 120 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.
May be followed by: THERAPY: PACLItaxel 175 mg/m2 IV Day 1; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 14 days;
COURSE: 4 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 and resulted: WBC, ANC, Platelets, 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 Total Bilirubin greater than 1.2 mg/dL or AST greater than 1.5X ULN.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
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ZZtestonc,Andrew [2428787]
11/1/2016 3:36:03 PM Page 3 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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,
Total Bilirubin, AST; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, cyclophosphamide for 120 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.
May be followed by: THERAPY: PACLItaxel 175 mg/m2 IV Day 1; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 14 days;
COURSE: 4 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 3:36:03 PM Page 4 of 14
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.
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 and resulted: WBC, ANC, Platelets, 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 Total Bilirubin greater than 1.2 mg/dL or AST greater than 1.5X ULN.
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.
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ZZtestonc,Andrew [2428787]
11/1/2016 3:36:03 PM Page 5 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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,
Total Bilirubin, AST; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, cyclophosphamide for 120 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.
May be followed by: THERAPY: PACLItaxel 175 mg/m2 IV Day 1; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 14 days;
COURSE: 4 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 and resulted: WBC, ANC, Platelets, 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 Total Bilirubin greater than 1.2 mg/dL or AST greater than 1.5X ULN.
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.
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ZZtestonc,Andrew [2428787]
11/1/2016 3:36:03 PM Page 6 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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 tablets 12&6h prior to 1st dose of PACLItaxel., Disp-10 tab, R-0, 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), AST;
CHEMOTHERAPY ROOM APPOINTMENT: First dose PACLItaxel for 210 minutes.
Cycle 5 – 12/27/2016 through 1/9/2017 (14 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.
May be followed by: THERAPY: PACLItaxel 175 mg/m2 IV Day 1; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 14 days;
COURSE: 4 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
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ZZtestonc,Andrew [2428787]
11/1/2016 3:36:03 PM Page 7 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

CBC WITHOUT DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
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, Total Bilirubin, AST.
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 AST
greater than 5 X ULN or Total Bilirubin greater than 1.25 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 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 18 mL 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
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ZZtestonc,Andrew [2428787]
11/1/2016 3:36:03 PM Page 8 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
PACLItaxel (TAXOL) 175 mg/m2 in dextrose 5 % 100 mL non-PVC bag
175 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 180 minutes. Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications. Use non-PVC tubing and 0.22 micron in-line filter during administration.
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-14 tab, R-0,
starting S, Local Printer
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed for nausea/vomiting., 8 mg, Disp-30 tab, R-5, EVERY 8 HOURS PRN starting S,
Local Printer
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), AST;
CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel for 210 minutes.
Cycle 6 – 1/10/2017 through 1/23/2017 (14 days), Planned
Day 1, Cycle 6 – 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.
May be followed by: THERAPY: PACLItaxel 175 mg/m2 IV Day 1; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 14 days;
COURSE: 4 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
AST/SGOT
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ZZtestonc,Andrew [2428787]
11/1/2016 3:36:03 PM Page 9 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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, Total Bilirubin, AST.
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 AST
greater than 5 X ULN or Total Bilirubin greater than 1.25 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 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 18 mL 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
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ZZtestonc,Andrew [2428787]
11/1/2016 3:36:03 PM Page 10 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
PACLItaxel (TAXOL) 175 mg/m2 in dextrose 5 % 100 mL non-PVC bag
175 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 180 minutes. Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications. Use non-PVC tubing and 0.22 micron in-line filter during administration.
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), AST;
CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel for 210 minutes.
Cycle 7 – 1/24/2017 through 2/6/2017 (14 days), Planned
Day 1, Cycle 7 – 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.
May be followed by: THERAPY: PACLItaxel 175 mg/m2 IV Day 1; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 14 days;
COURSE: 4 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
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, Total Bilirubin, AST.
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 AST
greater than 5 X ULN or Total Bilirubin greater than 1.25 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.
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ZZtestonc,Andrew [2428787]
11/1/2016 3:36:03 PM Page 11 of 14
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
Hypersensitivity Monitoring (1)
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 18 mL 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 30 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
PACLItaxel (TAXOL) 175 mg/m2 in dextrose 5 % 100 mL non-PVC bag
175 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 180 minutes. Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications. Use non-PVC tubing and 0.22 micron in-line filter during administration.
Follow-Up
DAY 15 FOLLOW-UP
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ZZtestonc,Andrew [2428787]
11/1/2016 3:36:03 PM Page 12 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done
locally), AST; CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel for 210 minutes.
Cycle 8 – 2/7/2017 through 2/20/2017 (14 days), Planned
Day 1, Cycle 8 – 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.
May be followed by: THERAPY: PACLItaxel 175 mg/m2 IV Day 1; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 14 days;
COURSE: 4 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
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, Total Bilirubin, AST.
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 AST
greater than 5 X ULN or Total Bilirubin greater than 1.25 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 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 18 mL 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 30 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
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ZZtestonc,Andrew [2428787]
11/1/2016 3:36:03 PM Page 13 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
PACLItaxel (TAXOL) 175 mg/m2 in dextrose 5 % 100 mL non-PVC bag
175 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 180 minutes. Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications. Use non-PVC tubing and 0.22 micron in-line filter during administration.
Follow-Up
DAY 29 FOLLOW-UP
RETURN TO CLINIC for appointment with provider in one month.
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ZZtestonc,Andrew [2428787]
11/1/2016 3:36:03 PM Page 14 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org