/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-96607-en.cckm

201611306

page

100

UWHC,UWMF,

Tools,

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

CSC Breast Cyclophosphamide (21D1), DOCEtaxel (21D1), Doxorubicin (21D1) VER 10-3-16(HL 576)

CSC Breast Cyclophosphamide (21D1), DOCEtaxel (21D1), Doxorubicin (21D1) VER 10-3-16(HL 576) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Breast


CSC BREAST CYCLOPHOSPHAMIDE(21D:1)/DOCETAXEL(21D:1)/DOXORUBICIN(21D:1) VER: 10-3-16 – Properties
Pre-Cycle – 10/25/2016 through 10/31/2016 (7 days), Planned
Day 1, Pre-Cycle – Planned for 10/25/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Adjuvant); THERAPY: doxorubicin 50 mg/m2 IV Day1, cyclophosphamide 500 mg/m2 IV Day 1,
DOCEtaxel 75 mg/m2 IV Day 1; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 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
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
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
prochlorperazine (COMPAZINE) 10 MG tab
Take 1 tab by mouth every 6 hours as needed (For nausea)., 10 mg, Disp-30 tab, R-5, EVERY 6 HOURS PRN starting S
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 11/21/2016 (21 days), Planned
Day 1, Cycle 1 – Planned for 11/1/2016
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ZZtestonc,Andrew [2428787]
11/1/2016 3:40:02 PM Page 1 of 13
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: Martin M, et al. NEJM 2005;352:2302-13.
Treatment Plan Summary
DISEASE: Breast Cancer (Adjuvant); THERAPY: doxorubicin 50 mg/m2 IV Day1, cyclophosphamide 500 mg/m2 IV Day 1,
DOCEtaxel 75 mg/m2 IV Day 1; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 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 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 DOCEtaxel can occur. For first and second dose, patient should be treated in a location to optimize emergency
care. See Emergency Medications.
** Rush dextrose primed line with 18mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the 1st and 2nd dose of DOCEtaxel administration and then every 30 minutes for
any subsequent doses.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
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ZZtestonc,Andrew [2428787]
11/1/2016 3:40:02 PM Page 2 of 13
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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.
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
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
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 50 mg/m2 (Treatment Plan)
50 mg/m2, Intravenous, ONCE, 1 dose Starting when released
IV side arm push 3-5 mL/minute into running IV.
cyclophosphamide (CYTOXAN) 500 mg/m2 in sodium chloride 0.9 % 250 mL bag
500 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Wait ONE HOUR after cyclophosphamide to administer DOCEtaxel.
DOCEtaxel (TAXOTERE) 75 mg/m2 in dextrose 5 % 100 mL non-PVC bag
75 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Wait ONE HOUR after cyclophosphamide to administer DOCEtaxel. In non-PVC
bag. Infuse through non PVC tubing.
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,
Total Bilirubin, AST; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, cyclophosphamide and DOCEtaxel for 210 minutes.
Cycle 2 – 11/22/2016 through 12/12/2016 (21 days), Planned
Day 1, Cycle 2 – Planned for 11/22/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Adjuvant); THERAPY: doxorubicin 50 mg/m2 IV Day1, cyclophosphamide 500 mg/m2 IV Day 1,
DOCEtaxel 75 mg/m2 IV Day 1; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 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.
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ZZtestonc,Andrew [2428787]
11/1/2016 3:40:02 PM Page 3 of 13
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 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 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 DOCEtaxel can occur. For first and second dose, patient should be treated in a location to optimize emergency
care. See Emergency Medications.
** Rush dextrose primed line with 18mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the 1st and 2nd dose of DOCEtaxel administration and then every 30 minutes for
any subsequent doses.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
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ZZtestonc,Andrew [2428787]
11/1/2016 3:40:02 PM Page 4 of 13
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

24 mg, Oral, ONCE, 1 dose Starting when released
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
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 50 mg/m2 (Treatment Plan)
50 mg/m2, Intravenous, ONCE, 1 dose Starting when released
IV side arm push 3-5 mL/minute into running IV.
cyclophosphamide (CYTOXAN) 500 mg/m2 in sodium chloride 0.9 % 250 mL bag
500 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Wait ONE HOUR after cyclophosphamide to administer DOCEtaxel.
DOCEtaxel (TAXOTERE) 75 mg/m2 in dextrose 5 % 100 mL non-PVC bag
75 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Wait ONE HOUR after cyclophosphamide to administer DOCEtaxel. In non-PVC
bag. Infuse through non PVC tubing.
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,
Total Bilirubin, AST; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, cyclophosphamide and DOCEtaxel for 210 minutes.
Cycle 3 – 12/13/2016 through 1/2/2017 (21 days), Planned
Day 1, Cycle 3 – Planned for 12/13/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Adjuvant); THERAPY: doxorubicin 50 mg/m2 IV Day1, cyclophosphamide 500 mg/m2 IV Day 1,
DOCEtaxel 75 mg/m2 IV Day 1; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 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
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ZZtestonc,Andrew [2428787]
11/1/2016 3:40:02 PM Page 5 of 13
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 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 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 DOCEtaxel can occur. For first and second dose, patient should be treated in a location to optimize emergency
care. See Emergency Medications.
** Rush dextrose primed line with 18mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Vital Signs
EVERY 30 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the 1st and 2nd dose of DOCEtaxel administration and then every 30 minutes for
any subsequent doses.
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
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
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ZZtestonc,Andrew [2428787]
11/1/2016 3:40:02 PM Page 6 of 13
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 50 mg/m2 (Treatment Plan)
50 mg/m2, Intravenous, ONCE, 1 dose Starting when released
IV side arm push 3-5 mL/minute into running IV.
cyclophosphamide (CYTOXAN) 500 mg/m2 in sodium chloride 0.9 % 250 mL bag
500 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Wait ONE HOUR after cyclophosphamide to administer DOCEtaxel.
DOCEtaxel (TAXOTERE) 75 mg/m2 in dextrose 5 % 100 mL non-PVC bag
75 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Wait ONE HOUR after cyclophosphamide to administer DOCEtaxel. In non-PVC
bag. Infuse through non PVC tubing.
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,
Total Bilirubin, AST; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, cyclophosphamide and DOCEtaxel for 210 minutes.
Cycle 4 – 1/3/2017 through 1/23/2017 (21 days), Planned
Day 1, Cycle 4 – Planned for 1/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Adjuvant); THERAPY: doxorubicin 50 mg/m2 IV Day1, cyclophosphamide 500 mg/m2 IV Day 1,
DOCEtaxel 75 mg/m2 IV Day 1; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 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
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
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ZZtestonc,Andrew [2428787]
11/1/2016 3:40:02 PM Page 7 of 13
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Verify Labs
Verify pretreatment labs have been obtained 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 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 DOCEtaxel can occur. For first and second dose, patient should be treated in a location to optimize emergency
care. See Emergency Medications.
** Rush dextrose primed line with 18mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Vital Signs
EVERY 30 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the 1st and 2nd dose of DOCEtaxel administration and then every 30 minutes for
any subsequent doses.
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
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
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ZZtestonc,Andrew [2428787]
11/1/2016 3:40:02 PM Page 8 of 13
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 50 mg/m2 (Treatment Plan)
50 mg/m2, Intravenous, ONCE, 1 dose Starting when released
IV side arm push 3-5 mL/minute into running IV.
cyclophosphamide (CYTOXAN) 500 mg/m2 in sodium chloride 0.9 % 250 mL bag
500 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Wait ONE HOUR after cyclophosphamide to administer DOCEtaxel.
DOCEtaxel (TAXOTERE) 75 mg/m2 in dextrose 5 % 100 mL non-PVC bag
75 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Wait ONE HOUR after cyclophosphamide to administer DOCEtaxel. In non-PVC
bag. Infuse through non PVC tubing.
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,
Total Bilirubin, AST; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, cyclophosphamide and DOCEtaxel for 210 minutes.
Cycle 5 – 1/24/2017 through 2/13/2017 (21 days), Planned
Day 1, Cycle 5 – Planned for 1/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Adjuvant); THERAPY: doxorubicin 50 mg/m2 IV Day1, cyclophosphamide 500 mg/m2 IV Day 1,
DOCEtaxel 75 mg/m2 IV Day 1; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 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
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 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 ULN, or AST greater than 1.5 X ULN or Total Bilirubin greater than ULN
Verify Medication(s) Taken at Home (1)
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ZZtestonc,Andrew [2428787]
11/1/2016 3:40:02 PM Page 9 of 13
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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 DOCEtaxel can occur. For first and second dose, patient should be treated in a location to optimize emergency
care. See Emergency Medications.
** Rush dextrose primed line with 18mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Vital Signs
EVERY 30 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the 1st and 2nd dose of DOCEtaxel administration and then every 30 minutes for
any subsequent doses.
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
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
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 50 mg/m2 (Treatment Plan)
50 mg/m2, Intravenous, ONCE, 1 dose Starting when released
IV side arm push 3-5 mL/minute into running IV.
cyclophosphamide (CYTOXAN) 500 mg/m2 in sodium chloride 0.9 % 250 mL bag
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ZZtestonc,Andrew [2428787]
11/1/2016 3:40:02 PM Page 10 of 13
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

500 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Wait ONE HOUR after cyclophosphamide to administer DOCEtaxel.
DOCEtaxel (TAXOTERE) 75 mg/m2 in dextrose 5 % 100 mL non-PVC bag
75 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Wait ONE HOUR after cyclophosphamide to administer DOCEtaxel. In non-PVC
bag. Infuse through non PVC tubing.
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,
Total Bilirubin, AST; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, cyclophosphamide and DOCEtaxel for 210 minutes.
Cycle 6 – 2/14/2017 through 3/6/2017 (21 days), Planned
Day 1, Cycle 6 – Planned for 2/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Adjuvant); THERAPY: doxorubicin 50 mg/m2 IV Day1, cyclophosphamide 500 mg/m2 IV Day 1,
DOCEtaxel 75 mg/m2 IV Day 1; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 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
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 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 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 DOCEtaxel can occur. For first and second dose, patient should be treated in a location to optimize emergency
care. See Emergency Medications.
** Rush dextrose primed line with 18mL prior to programming start rate for infusion.
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ZZtestonc,Andrew [2428787]
11/1/2016 3:40:02 PM Page 11 of 13
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

** 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 1st and 2nd dose of DOCEtaxel administration and then every 30 minutes for
any subsequent doses.
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
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
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 50 mg/m2 (Treatment Plan)
50 mg/m2, Intravenous, ONCE, 1 dose Starting when released
IV side arm push 3-5 mL/minute into running IV.
cyclophosphamide (CYTOXAN) 500 mg/m2 in sodium chloride 0.9 % 250 mL bag
500 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Wait ONE HOUR after cyclophosphamide to administer DOCEtaxel.
DOCEtaxel (TAXOTERE) 75 mg/m2 in dextrose 5 % 100 mL non-PVC bag
75 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Wait ONE HOUR after cyclophosphamide to administer DOCEtaxel. In non-PVC
bag. Infuse through non PVC tubing.
Follow-Up
DAY 22 FOLLOW-UP
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ZZtestonc,Andrew [2428787]
11/1/2016 3:40:02 PM Page 12 of 13
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), Creatinine, Total Bilirubin, AST; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin,
cyclophosphamide and DOCEtaxel for 210 minutes.
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ZZtestonc,Andrew [2428787]
11/1/2016 3:40:02 PM Page 13 of 13
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org