/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-96615-en.cckm

201611306

page

100

UWHC,UWMF,

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

CSC Breast PACLItaxel (28D1,8,15,22) VER 10-3-16 (HL 4309)

CSC Breast PACLItaxel (28D1,8,15,22) VER 10-3-16 (HL 4309) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Breast


CSC BREAST PACLITAXEL (28D:1,8,15,22) 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: PACLItaxel 80 mg/m2 IV Day 1, 8, 15 and 22; 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
CREATININE
Expected-S Approximate, Expires-S+365, Routine
CALCIUM
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
ALKALINE PHOSPHATASE
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
dexamethasone (DECADRON) 4 MG tab
Take 5 tabs 12 and 6 hours prior to first PACLItaxel dose in Cycle 1., Disp-10 tab, R-0, 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: Perez EA, et al. J Clin Oncol 2001;19:4216-23.
Reference Information (2)
BREAST CANCER: Nabholtz JM, et al. J Clin Oncol 1996;14:1858-67.
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: PACLItaxel 80 mg/m2 IV Day 1, 8, 15 and 22; CYCLE LENGTH: 28 days;
COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
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ZZtestonc,Andrew [2428787]
11/1/2016 4:27:46 PM Page 1 of 42
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
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 or Platelets less than 100K/µL or Creatinine greater
than 1.5 X ULN or Total Bilirubin greater than or equal to 1.25 X ULN or AST greater than or equal to 5 X ULN.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to 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
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.
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
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ZZtestonc,Andrew [2428787]
11/1/2016 4:27:46 PM Page 2 of 42
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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) 80 mg/m2 in dextrose 5 % 100 mL non-PVC bag
80 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Infuse through non-PVC containing tubing and 0.22 micron in-line non-DEHP (non-PVC) filter during administration. Administer over
60 minutes. Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
Take 3 tabs 12&6 hrs prior to 2nd PACLItaxel dose and 2 tabs 12&6 hrs prior to remaining PACLItaxel doses., Disp-50 tab, R-3,
starting S
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel for 120 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel for 120 minutes.
DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel for 120 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Creatinine,
Calcium, Total Bilirubin, AST, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel for 120 minutes.
Day 8, Cycle 1 – Planned for 11/8/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: PACLItaxel 80 mg/m2 IV Day 1, 8, 15 and 22; 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+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
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ZZtestonc,Andrew [2428787]
11/1/2016 4:27:46 PM Page 3 of 42
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to 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
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
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ZZtestonc,Andrew [2428787]
11/1/2016 4:27:46 PM Page 4 of 42
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 80 mg/m2 in dextrose 5 % 100 mL non-PVC bag
80 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Infuse through non-PVC containing tubing and 0.22 micron in-line non-DEHP (non-PVC) filter during administration. Administer over
60 minutes. Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 1 – Planned for 11/15/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: PACLItaxel 80 mg/m2 IV Day 1, 8, 15 and 22; 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+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to 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
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ZZtestonc,Andrew [2428787]
11/1/2016 4:27:46 PM Page 5 of 42
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) 80 mg/m2 in dextrose 5 % 100 mL non-PVC bag
80 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Infuse through non-PVC containing tubing and 0.22 micron in-line non-DEHP (non-PVC) filter during administration. Administer over
60 minutes. Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 1 – Planned for 11/22/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: PACLItaxel 80 mg/m2 IV Day 1, 8, 15 and 22; CYCLE LENGTH: 28 days;
COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
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ZZtestonc,Andrew [2428787]
11/1/2016 4:27:46 PM Page 6 of 42
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to 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
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ZZtestonc,Andrew [2428787]
11/1/2016 4:27:46 PM Page 7 of 42
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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) 80 mg/m2 in dextrose 5 % 100 mL non-PVC bag
80 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Infuse through non-PVC containing tubing and 0.22 micron in-line non-DEHP (non-PVC) filter during administration. Administer over
60 minutes. Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 11/29/2016 through 12/26/2016 (28 days), Planned
Day 1, Cycle 2 – Planned for 11/29/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: PACLItaxel 80 mg/m2 IV Day 1, 8, 15 and 22; 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+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
AST/SGOT
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ZZtestonc,Andrew [2428787]
11/1/2016 4:27:46 PM Page 8 of 42
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Expected-S+7 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+7 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 or Platelets less than 100K/µL or Creatinine greater
than 1.5 X ULN or Total Bilirubin greater than or equal to 1.25 X ULN or AST greater than or equal to 5 X ULN.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to 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 4:27:46 PM Page 9 of 42
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) 80 mg/m2 in dextrose 5 % 100 mL non-PVC bag
80 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Infuse through non-PVC containing tubing and 0.22 micron in-line non-DEHP (non-PVC) filter during administration. Administer over
60 minutes. Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel for 120 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel for 120 minutes.
DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel for 120 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Creatinine,
Calcium, Total Bilirubin, AST, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel for 120 minutes.
Day 8, Cycle 2 – Planned for 12/6/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: PACLItaxel 80 mg/m2 IV Day 1, 8, 15 and 22; 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+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
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ZZtestonc,Andrew [2428787]
11/1/2016 4:27:46 PM Page 10 of 42
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
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) 80 mg/m2 in dextrose 5 % 100 mL non-PVC bag
80 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Infuse through non-PVC containing tubing and 0.22 micron in-line non-DEHP (non-PVC) filter during administration. Administer over
60 minutes. Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Follow-Up
VERIFY APPOINTMENTS
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ZZtestonc,Andrew [2428787]
11/1/2016 4:27:46 PM Page 11 of 42
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 2 – Planned for 12/13/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: PACLItaxel 80 mg/m2 IV Day 1, 8, 15 and 22; 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+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to 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.
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ZZtestonc,Andrew [2428787]
11/1/2016 4:27:46 PM Page 12 of 42
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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) 80 mg/m2 in dextrose 5 % 100 mL non-PVC bag
80 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Infuse through non-PVC containing tubing and 0.22 micron in-line non-DEHP (non-PVC) filter during administration. Administer over
60 minutes. Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 2 – Planned for 12/20/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: PACLItaxel 80 mg/m2 IV Day 1, 8, 15 and 22; 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+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
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ZZtestonc,Andrew [2428787]
11/1/2016 4:27:46 PM Page 13 of 42
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to 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
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
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ZZtestonc,Andrew [2428787]
11/1/2016 4:27:46 PM Page 14 of 42
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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) 80 mg/m2 in dextrose 5 % 100 mL non-PVC bag
80 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Infuse through non-PVC containing tubing and 0.22 micron in-line non-DEHP (non-PVC) filter during administration. Administer over
60 minutes. Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 – 12/27/2016 through 1/23/2017 (28 days), Planned
Day 1, Cycle 3 – Planned for 12/27/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: PACLItaxel 80 mg/m2 IV Day 1, 8, 15 and 22; 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+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+7 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 or Platelets less than 100K/µL or Creatinine greater
than 1.5 X ULN or Total Bilirubin greater than or equal to 1.25 X ULN or AST greater than or equal to 5 X ULN.
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ZZtestonc,Andrew [2428787]
11/1/2016 4:27:46 PM Page 15 of 42
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to 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
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) 80 mg/m2 in dextrose 5 % 100 mL non-PVC bag
80 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Infuse through non-PVC containing tubing and 0.22 micron in-line non-DEHP (non-PVC) filter during administration. Administer over
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ZZtestonc,Andrew [2428787]
11/1/2016 4:27:46 PM Page 16 of 42
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

60 minutes. Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel for 120 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel for 120 minutes.
DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel for 120 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Creatinine,
Calcium, Total Bilirubin, AST, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel for 120 minutes.
Day 8, Cycle 3 – Planned for 1/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: PACLItaxel 80 mg/m2 IV Day 1, 8, 15 and 22; 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+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to 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.
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ZZtestonc,Andrew [2428787]
11/1/2016 4:27:46 PM Page 17 of 42
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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) 80 mg/m2 in dextrose 5 % 100 mL non-PVC bag
80 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Infuse through non-PVC containing tubing and 0.22 micron in-line non-DEHP (non-PVC) filter during administration. Administer over
60 minutes. Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 3 – Planned for 1/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: PACLItaxel 80 mg/m2 IV Day 1, 8, 15 and 22; CYCLE LENGTH: 28 days;
COURSE: until disease progression.
Consent
Verify Consent
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ZZtestonc,Andrew [2428787]
11/1/2016 4:27:46 PM Page 18 of 42
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to 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
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ZZtestonc,Andrew [2428787]
11/1/2016 4:27:46 PM Page 19 of 42
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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) 80 mg/m2 in dextrose 5 % 100 mL non-PVC bag
80 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Infuse through non-PVC containing tubing and 0.22 micron in-line non-DEHP (non-PVC) filter during administration. Administer over
60 minutes. Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 3 – Planned for 1/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: PACLItaxel 80 mg/m2 IV Day 1, 8, 15 and 22; 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+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
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ZZtestonc,Andrew [2428787]
11/1/2016 4:27:46 PM Page 20 of 42
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 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 80 mg/m2 in dextrose 5 % 100 mL non-PVC bag
80 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Infuse through non-PVC containing tubing and 0.22 micron in-line non-DEHP (non-PVC) filter during administration. Administer over
60 minutes. Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Follow-Up
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ZZtestonc,Andrew [2428787]
11/1/2016 4:27:46 PM Page 21 of 42
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 – 1/24/2017 through 2/20/2017 (28 days), Planned
Day 1, Cycle 4 – Planned for 1/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: PACLItaxel 80 mg/m2 IV Day 1, 8, 15 and 22; 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+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+7 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 or Platelets less than 100K/µL or Creatinine greater
than 1.5 X ULN or Total Bilirubin greater than or equal to 1.25 X ULN or AST greater than or equal to 5 X ULN.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to 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.
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ZZtestonc,Andrew [2428787]
11/1/2016 4:27:46 PM Page 22 of 42
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 80 mg/m2 in dextrose 5 % 100 mL non-PVC bag
80 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Infuse through non-PVC containing tubing and 0.22 micron in-line non-DEHP (non-PVC) filter during administration. Administer over
60 minutes. Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel for 120 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel for 120 minutes.
DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel for 120 minutes.
DAY 29 FOLLOW-UP
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ZZtestonc,Andrew [2428787]
11/1/2016 4:27:46 PM Page 23 of 42
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 done locally),
Creatinine, Calcium, Total Bilirubin, AST, Alkaline Phosphatase; CHEMOTHERAPY ROOM
APPOINTMENT: PACLItaxel for 120 minutes.
Day 8, Cycle 4 – Planned for 1/31/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: PACLItaxel 80 mg/m2 IV Day 1, 8, 15 and 22; 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+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to 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
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ZZtestonc,Andrew [2428787]
11/1/2016 4:27:46 PM Page 24 of 42
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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) 80 mg/m2 in dextrose 5 % 100 mL non-PVC bag
80 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Infuse through non-PVC containing tubing and 0.22 micron in-line non-DEHP (non-PVC) filter during administration. Administer over
60 minutes. Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 4 – Planned for 2/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: PACLItaxel 80 mg/m2 IV Day 1, 8, 15 and 22; 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
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ZZtestonc,Andrew [2428787]
11/1/2016 4:27:46 PM Page 25 of 42
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to 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 4:27:46 PM Page 26 of 42
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) 80 mg/m2 in dextrose 5 % 100 mL non-PVC bag
80 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Infuse through non-PVC containing tubing and 0.22 micron in-line non-DEHP (non-PVC) filter during administration. Administer over
60 minutes. Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 4 – Planned for 2/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: PACLItaxel 80 mg/m2 IV Day 1, 8, 15 and 22; 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+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to 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
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ZZtestonc,Andrew [2428787]
11/1/2016 4:27:46 PM Page 27 of 42
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 80 mg/m2 in dextrose 5 % 100 mL non-PVC bag
80 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Infuse through non-PVC containing tubing and 0.22 micron in-line non-DEHP (non-PVC) filter during administration. Administer over
60 minutes. Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 – 2/21/2017 through 3/20/2017 (28 days), Planned
Day 1, Cycle 5 – Planned for 2/21/2017
Treatment Plan Information
Treatment Plan Summary
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ZZtestonc,Andrew [2428787]
11/1/2016 4:27:46 PM Page 28 of 42
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DISEASE: Breast Cancer (Advanced); THERAPY: PACLItaxel 80 mg/m2 IV Day 1, 8, 15 and 22; 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+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+7 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 or Platelets less than 100K/µL or Creatinine greater
than 1.5 X ULN or Total Bilirubin greater than or equal to 1.25 X ULN or AST greater than or equal to 5 X ULN.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to 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.
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ZZtestonc,Andrew [2428787]
11/1/2016 4:27:46 PM Page 29 of 42
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 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) 80 mg/m2 in dextrose 5 % 100 mL non-PVC bag
80 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Infuse through non-PVC containing tubing and 0.22 micron in-line non-DEHP (non-PVC) filter during administration. Administer over
60 minutes. Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel for 120 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel for 120 minutes.
DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel for 120 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Creatinine,
Calcium, Total Bilirubin, AST, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel for 120 minutes.
Day 8, Cycle 5 – Planned for 2/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: PACLItaxel 80 mg/m2 IV Day 1, 8, 15 and 22; CYCLE LENGTH: 28 days;
COURSE: until disease progression.
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ZZtestonc,Andrew [2428787]
11/1/2016 4:27:46 PM Page 30 of 42
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to 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
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ZZtestonc,Andrew [2428787]
11/1/2016 4:27:46 PM Page 31 of 42
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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) 80 mg/m2 in dextrose 5 % 100 mL non-PVC bag
80 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Infuse through non-PVC containing tubing and 0.22 micron in-line non-DEHP (non-PVC) filter during administration. Administer over
60 minutes. Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 5 – Planned for 3/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: PACLItaxel 80 mg/m2 IV Day 1, 8, 15 and 22; 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+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
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ZZtestonc,Andrew [2428787]
11/1/2016 4:27:46 PM Page 32 of 42
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to 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
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) 80 mg/m2 in dextrose 5 % 100 mL non-PVC bag
80 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Infuse through non-PVC containing tubing and 0.22 micron in-line non-DEHP (non-PVC) filter during administration. Administer over
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ZZtestonc,Andrew [2428787]
11/1/2016 4:27:46 PM Page 33 of 42
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

60 minutes. Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 5 – Planned for 3/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: PACLItaxel 80 mg/m2 IV Day 1, 8, 15 and 22; 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+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to 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
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ZZtestonc,Andrew [2428787]
11/1/2016 4:27:46 PM Page 34 of 42
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 80 mg/m2 in dextrose 5 % 100 mL non-PVC bag
80 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Infuse through non-PVC containing tubing and 0.22 micron in-line non-DEHP (non-PVC) filter during administration. Administer over
60 minutes. Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 6 – 3/21/2017 through 4/17/2017 (28 days), Planned
Day 1, Cycle 6 – Planned for 3/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: PACLItaxel 80 mg/m2 IV Day 1, 8, 15 and 22; 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 4:27:46 PM Page 35 of 42
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+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+7 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 or Platelets less than 100K/µL or Creatinine greater
than 1.5 X ULN or Total Bilirubin greater than or equal to 1.25 X ULN or AST greater than or equal to 5 X ULN.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to 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
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ZZtestonc,Andrew [2428787]
11/1/2016 4:27:46 PM Page 36 of 42
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 80 mg/m2 in dextrose 5 % 100 mL non-PVC bag
80 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Infuse through non-PVC containing tubing and 0.22 micron in-line non-DEHP (non-PVC) filter during administration. Administer over
60 minutes. Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel for 120 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel for 120 minutes.
DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel for 120 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Creatinine,
Calcium, Total Bilirubin, AST, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel for 120 minutes.
Day 8, Cycle 6 – Planned for 3/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: PACLItaxel 80 mg/m2 IV Day 1, 8, 15 and 22; 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.
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ZZtestonc,Andrew [2428787]
11/1/2016 4:27:46 PM Page 37 of 42
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+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to 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
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ZZtestonc,Andrew [2428787]
11/1/2016 4:27:46 PM Page 38 of 42
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
PACLItaxel (TAXOL) 80 mg/m2 in dextrose 5 % 100 mL non-PVC bag
80 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Infuse through non-PVC containing tubing and 0.22 micron in-line non-DEHP (non-PVC) filter during administration. Administer over
60 minutes. Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 6 – Planned for 4/4/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: PACLItaxel 80 mg/m2 IV Day 1, 8, 15 and 22; 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+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to 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
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ZZtestonc,Andrew [2428787]
11/1/2016 4:27:46 PM Page 39 of 42
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 80 mg/m2 in dextrose 5 % 100 mL non-PVC bag
80 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Infuse through non-PVC containing tubing and 0.22 micron in-line non-DEHP (non-PVC) filter during administration. Administer over
60 minutes. Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 6 – Planned for 4/11/2017
Treatment Plan Information
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ZZtestonc,Andrew [2428787]
11/1/2016 4:27:46 PM Page 40 of 42
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: PACLItaxel 80 mg/m2 IV Day 1, 8, 15 and 22; 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+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to 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
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ZZtestonc,Andrew [2428787]
11/1/2016 4:27:46 PM Page 41 of 42
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to chemotherapy.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Administer 30 minutes PRIOR to chemotherapy
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 80 mg/m2 in dextrose 5 % 100 mL non-PVC bag
80 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Infuse through non-PVC containing tubing and 0.22 micron in-line non-DEHP (non-PVC) filter during administration. Administer over
60 minutes. Hypersensitivity to PACLItaxel can occur. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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ZZtestonc,Andrew [2428787]
11/1/2016 4:27:46 PM Page 42 of 42
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org