/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-96612-en.cckm

201611306

page

100

UWHC,UWMF,

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

CSC Breast Liposomal Doxorubicin (28D1) VER 10-3-16 (HL 571)

CSC Breast Liposomal Doxorubicin (28D1) VER 10-3-16 (HL 571) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Breast


CSC BREAST LIPOSOMAL DOXORUBICIN(28D: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 (Advanced); THERAPY: doxorubicin LIPOSOMAL 40 mg/m2 IV Day 1 (Dose varies from reference);
CYCLE LENGTH: 28 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
Take Home Medications
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
Cycle 1 – 11/1/2016 through 11/28/2016 (28 days), Planned
Day 1, Cycle 1 – Planned for 11/1/2016
Treatment Plan Information
Reference Information (1)
BREAST CANCER: Ranson MR, et al. J Clin Onc 1997;15:3185-91.
Reference Information (2)
BREAST CANCER: Harris L, et al. Cancer 2002;94:25-36
Reference Information (3)
BREAST CANCER: Keller AM, et al. J Clin Oncol:2004;22:3893-901.
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: doxorubicin LIPOSOMAL 40 mg/m2 IV Day 1 (Dose varies from reference);
CYCLE LENGTH: 28 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Total Bilirubin.
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ZZtestonc,Andrew [2428787]
11/1/2016 4:26:06 PM Page 1 of 11
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to
100K/µL or Total Bilirubin greater than ULN
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to doxorubicin LIPOSOMAL can occur. For first and second dose, patient should be treated in a location to
optimize emergency care.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first and second dose of doxorubicin LIPOSOMAL 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 1,000 mL
at 500-999 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL over 1-2 hours before doxorubicin LIPOSOMAL to decrease incidence of hand-foot syndrome.
Flush line with D5W before and after infusion of doxorubicin LIPOSOMAL (incompatible with NS).
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Flush line with 50 mL D5W before and after infusion of doxorubicin LIPOSOMAL (incompatible with NS).
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 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
doxorubicin LIPOSOMAL (DOXIL) 40 mg/m2 in dextrose 5 % 250 mL bag
40 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer FIRST dose as follows: start at 50 mL/hour for 15 Minutes: If tolerated increase to 100 mL/hour for 15 minutes: If
tolerated increase to final rate over 60 minutes. Subsequest doses may be administered over 60 minutes. Hypersensitivity reaction
to doxorubicin LIPOSOMAL can occur. For first and second dose, patient should be treated in a location to optimize emergency
care. See Emergency Medications.
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ZZtestonc,Andrew [2428787]
11/1/2016 4:26:06 PM Page 2 of 11
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally);
CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin LIPOSOMAL for 90 minutes.
Cycle 2 – 11/29/2016 through 12/26/2016 (28 days), Planned
Day 1, Cycle 2 – Planned for 11/29/2016
Treatment Plan Information
Reference Information (1)
BREAST CANCER: Ranson MR, et al. J Clin Onc 1997;15:3185-91.
Reference Information (2)
BREAST CANCER: Harris L, et al. Cancer 2002;94:25-36
Reference Information (3)
BREAST CANCER: Keller AM, et al. J Clin Oncol:2004;22:3893-901.
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: doxorubicin LIPOSOMAL 40 mg/m2 IV Day 1 (Dose varies from reference);
CYCLE LENGTH: 28 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL or Total
Bilirubin greater than ULN
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to doxorubicin LIPOSOMAL can occur. For first and second dose, patient should be treated in a location to
optimize emergency care.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first and second dose of liposomal doxorubicin and then every 30 minutes for
any subsequent doses.
Flush Venous Access Device per Guidelines
Order details
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ZZtestonc,Andrew [2428787]
11/1/2016 4:26:06 PM Page 3 of 11
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 1,000 mL
at 500-999 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL over 1-2 hours before doxorubicin LIPOSOMAL to decrease incidence of hand-foot syndrome.
Flush line with D5W before and after infusion of doxorubicin LIPOSOMAL (incompatible with NS).
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Flush line with 50 mL D5W before and after infusion of doxorubicin LIPOSOMAL (incompatible with NS).
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 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
doxorubicin LIPOSOMAL (DOXIL) 40 mg/m2 in dextrose 5 % 250 mL bag
40 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer FIRST dose as follows: start at 50 mL/hour for 15 Minutes: If tolerated increase to 100 mL/hour for 15 minutes: If
tolerated increase to final rate over 60 minutes. Subsequest doses may be administered over 60 minutes. Hypersensitivity reaction
to doxorubicin LIPOSOMAL can occur. For first and second dose, patient should be treated in a location to optimize emergency
care. See Emergency Medications.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally);
CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin LIPOSOMAL for 90 minutes.
Cycle 3 – 12/27/2016 through 1/23/2017 (28 days), Planned
Day 1, Cycle 3 – Planned for 12/27/2016
Treatment Plan Information
Reference Information (1)
BREAST CANCER: Ranson MR, et al. J Clin Onc 1997;15:3185-91.
Reference Information (2)
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ZZtestonc,Andrew [2428787]
11/1/2016 4:26:06 PM Page 4 of 11
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

BREAST CANCER: Harris L, et al. Cancer 2002;94:25-36
Reference Information (3)
BREAST CANCER: Keller AM, et al. J Clin Oncol:2004;22:3893-901.
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: doxorubicin LIPOSOMAL 40 mg/m2 IV Day 1 (Dose varies from reference);
CYCLE LENGTH: 28 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL or Total
Bilirubin greater than ULN
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to doxorubicin LIPOSOMAL can occur. For first and second dose, patient should be treated in a location to
optimize emergency care.
Vital Signs
EVERY 30 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first and second dose of liposomal doxorubicin 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 1,000 mL
at 500-999 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL over 1-2 hours before doxorubicin LIPOSOMAL to decrease incidence of hand-foot syndrome.
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ZZtestonc,Andrew [2428787]
11/1/2016 4:26:06 PM Page 5 of 11
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Flush line with D5W before and after infusion of doxorubicin LIPOSOMAL (incompatible with NS).
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Flush line with 50 mL D5W before and after infusion of doxorubicin LIPOSOMAL (incompatible with NS).
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 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
doxorubicin LIPOSOMAL (DOXIL) 40 mg/m2 in dextrose 5 % 250 mL bag
40 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer FIRST dose as follows: start at 50 mL/hour for 15 Minutes: If tolerated increase to 100 mL/hour for 15 minutes: If
tolerated increase to final rate over 60 minutes. Subsequest doses may be administered over 60 minutes. Hypersensitivity reaction
to doxorubicin LIPOSOMAL can occur. For first and second dose, patient should be treated in a location to optimize emergency
care. See Emergency Medications.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally);
CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin LIPOSOMAL for 90 minutes.
Cycle 4 – 1/24/2017 through 2/20/2017 (28 days), Planned
Day 1, Cycle 4 – Planned for 1/24/2017
Treatment Plan Information
Reference Information (1)
BREAST CANCER: Ranson MR, et al. J Clin Onc 1997;15:3185-91.
Reference Information (2)
BREAST CANCER: Harris L, et al. Cancer 2002;94:25-36
Reference Information (3)
BREAST CANCER: Keller AM, et al. J Clin Oncol:2004;22:3893-901.
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: doxorubicin LIPOSOMAL 40 mg/m2 IV Day 1 (Dose varies from reference);
CYCLE LENGTH: 28 days; COURSE: until disease progression.
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 4:26:06 PM Page 6 of 11
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+28 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL or Total
Bilirubin greater than ULN
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to doxorubicin LIPOSOMAL can occur. For first and second dose, patient should be treated in a location to
optimize emergency care.
Vital Signs
EVERY 30 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first and second dose of liposomal doxorubicin 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 1,000 mL
at 500-999 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL over 1-2 hours before doxorubicin LIPOSOMAL to decrease incidence of hand-foot syndrome.
Flush line with D5W before and after infusion of doxorubicin LIPOSOMAL (incompatible with NS).
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Flush line with 50 mL D5W before and after infusion of doxorubicin LIPOSOMAL (incompatible with NS).
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 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
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ZZtestonc,Andrew [2428787]
11/1/2016 4:26:06 PM Page 7 of 11
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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 LIPOSOMAL (DOXIL) 40 mg/m2 in dextrose 5 % 250 mL bag
40 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer FIRST dose as follows: start at 50 mL/hour for 15 Minutes: If tolerated increase to 100 mL/hour for 15 minutes: If
tolerated increase to final rate over 60 minutes. Subsequest doses may be administered over 60 minutes. Hypersensitivity reaction
to doxorubicin LIPOSOMAL can occur. For first and second dose, patient should be treated in a location to optimize emergency
care. See Emergency Medications.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally);
CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin LIPOSOMAL for 90 minutes.
Cycle 5 – 2/21/2017 through 3/20/2017 (28 days), Planned
Day 1, Cycle 5 – Planned for 2/21/2017
Treatment Plan Information
Reference Information (1)
BREAST CANCER: Ranson MR, et al. J Clin Onc 1997;15:3185-91.
Reference Information (2)
BREAST CANCER: Harris L, et al. Cancer 2002;94:25-36
Reference Information (3)
BREAST CANCER: Keller AM, et al. J Clin Oncol:2004;22:3893-901.
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: doxorubicin LIPOSOMAL 40 mg/m2 IV Day 1 (Dose varies from reference);
CYCLE LENGTH: 28 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
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ZZtestonc,Andrew [2428787]
11/1/2016 4:26:06 PM Page 8 of 11
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Verify pretreatment labs have been obtained: CBC, ANC, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL or Total
Bilirubin greater than ULN
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to doxorubicin LIPOSOMAL can occur. For first and second dose, patient should be treated in a location to
optimize emergency care.
Vital Signs
EVERY 30 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first and second dose of liposomal doxorubicin 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 1,000 mL
at 500-999 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL over 1-2 hours before doxorubicin LIPOSOMAL to decrease incidence of hand-foot syndrome.
Flush line with D5W before and after infusion of doxorubicin LIPOSOMAL (incompatible with NS).
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Flush line with 50 mL D5W before and after infusion of doxorubicin LIPOSOMAL (incompatible with NS).
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 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
doxorubicin LIPOSOMAL (DOXIL) 40 mg/m2 in dextrose 5 % 250 mL bag
40 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer FIRST dose as follows: start at 50 mL/hour for 15 Minutes: If tolerated increase to 100 mL/hour for 15 minutes: If
tolerated increase to final rate over 60 minutes. Subsequest doses may be administered over 60 minutes. Hypersensitivity reaction
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ZZtestonc,Andrew [2428787]
11/1/2016 4:26:06 PM Page 9 of 11
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

to doxorubicin LIPOSOMAL can occur. For first and second dose, patient should be treated in a location to optimize emergency
care. See Emergency Medications.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally);
CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin LIPOSOMAL for 90 minutes.
Cycle 6 – 3/21/2017 through 4/17/2017 (28 days), Planned
Day 1, Cycle 6 – Planned for 3/21/2017
Treatment Plan Information
Reference Information (1)
BREAST CANCER: Ranson MR, et al. J Clin Onc 1997;15:3185-91.
Reference Information (2)
BREAST CANCER: Harris L, et al. Cancer 2002;94:25-36
Reference Information (3)
BREAST CANCER: Keller AM, et al. J Clin Oncol:2004;22:3893-901.
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: doxorubicin LIPOSOMAL 40 mg/m2 IV Day 1 (Dose varies from reference);
CYCLE LENGTH: 28 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL or Total
Bilirubin greater than ULN
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to doxorubicin LIPOSOMAL can occur. For first and second dose, patient should be treated in a location to
optimize emergency care.
Vital Signs
EVERY 30 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first and second dose of liposomal doxorubicin and then every 30 minutes for
any subsequent doses.
Flush Venous Access Device per Guidelines
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ZZtestonc,Andrew [2428787]
11/1/2016 4:26:06 PM Page 10 of 11
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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 1,000 mL
at 500-999 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL over 1-2 hours before doxorubicin LIPOSOMAL to decrease incidence of hand-foot syndrome.
Flush line with D5W before and after infusion of doxorubicin LIPOSOMAL (incompatible with NS).
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Flush line with 50 mL D5W before and after infusion of doxorubicin LIPOSOMAL (incompatible with NS).
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 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
doxorubicin LIPOSOMAL (DOXIL) 40 mg/m2 in dextrose 5 % 250 mL bag
40 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer FIRST dose as follows: start at 50 mL/hour for 15 Minutes: If tolerated increase to 100 mL/hour for 15 minutes: If
tolerated increase to final rate over 60 minutes. Subsequest doses may be administered over 60 minutes. Hypersensitivity reaction
to doxorubicin LIPOSOMAL can occur. For first and second dose, patient should be treated in a location to optimize emergency
care. See Emergency Medications.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally);
CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin LIPOSOMAL for 90 minutes.
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ZZtestonc,Andrew [2428787]
11/1/2016 4:26:06 PM Page 11 of 11
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org