/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-96616-en.cckm

201611312

page

100

UWHC,UWMF,

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

CSC Breast PACLItaxel Protein Bound (28D1,8,15), Trastuzumab (28D1,8,15,22) VER 10-3-16 (HL 3056)

CSC Breast PACLItaxel Protein Bound (28D1,8,15), Trastuzumab (28D1,8,15,22) VER 10-3-16 (HL 3056) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Breast


CSC BREAST PACLITAXEL PROTEIN BOUND PARTICLES(28D:1,8,15)/TRASTUZUMAB(28D:1,8,15,22) VER: 10-3-
16 – Properties
Pre-Cycle – 10/31/2016 through 11/6/2016 (7 days), Planned
Day 1, Pre-Cycle – Planned for 10/31/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: trastuzumab 4 mg/kg IV Day 1, trastuzumab 2 mg/kg IV Day 8, 15, and 22,
PACLItaxel Protein Bound Particles 120 mg/m2 IV Day 1, 8, 15; CYCLE LENGTH: 28 days; COURSE: 1 cycle followed by
THERAPY: trastuzumab 2 mg/kg IV Day 1, 8, 15, 22, PACLItaxel Protein Bound Particiles 120 mg/m2 IV Day 1, 8, 15; 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
Cycle 1 – 11/7/2016 through 12/4/2016 (28 days), Planned
Day 1, Cycle 1 – Planned for 11/7/2016
Treatment Plan Information
Reference Information (1)
BREAST CANCER: Mirtsching et al. J Clin Oncol 26: 2008 (May 20 suppl; abstr 1118).
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: trastuzumab 4 mg/kg IV Day 1, trastuzumab 2 mg/kg IV Day 8, 15, and 22,
PACLItaxel Protein Bound Particles 120 mg/m2 IV Day 1, 8, 15; CYCLE LENGTH: 28 days; COURSE: 1 cycle followed by
THERAPY: trastuzumab 2 mg/kg IV Day 1, 8, 15, 22, PACLItaxel Protein Bound Particiles 120 mg/m2 IV Day 1, 8, 15; 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]
11/7/2016 1:16:59 PM Page 1 of 35
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.
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.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to trastuzumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient must be monitored for one hour after the first dose of trastuzumab. See Emergency Medications.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 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
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
trastuzumab (HERCEPTIN) 318 mg in sodium chloride 0.9 % 250 mL bag
318 mg (rounded from 317.6 mg = 4 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy. Give first dose over
60 minutes and subsequent doses over 30 minutes. Patient must be monitored for one hour after the first dose of trastuzumab.
PACLItaxel protein-bound (ABRAXANE) bag NF 120 mg/m2 (Treatment Plan)
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ZZtestonc,Andrew [2428787]
11/7/2016 1:16:59 PM Page 2 of 35
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

120 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 30 Minutes
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally); CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel Protein Bound Particles and
trastuzumab 120 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally); CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel Protein Bound Particles and
trastuzumab 90 minutes.
DAY 22 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: trastuzumab for 60 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 Protein Bound
Particles and trastuzumab for 90 minutes.
Day 8, Cycle 1 – Planned for 11/14/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: trastuzumab 4 mg/kg IV Day 1, trastuzumab 2 mg/kg IV Day 8, 15, and 22,
PACLItaxel Protein Bound Particles 120 mg/m2 IV Day 1, 8, 15; CYCLE LENGTH: 28 days; COURSE: 1 cycle followed by
THERAPY: trastuzumab 2 mg/kg IV Day 1, 8, 15, 22, PACLItaxel Protein Bound Particiles 120 mg/m2 IV Day 1, 8, 15; CYCLE
LENGTH: 28 days; COURSE: until disease progression.
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 100K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to trastuzumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient must be monitored for one hour after the first dose of trastuzumab. See Emergency Medications.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 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]
11/7/2016 1:16:59 PM Page 3 of 35
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
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
trastuzumab (HERCEPTIN) 159 mg in sodium chloride 0.9 % 250 mL bag
159 mg (rounded from 158.8 mg = 2 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy. Give first dose over
60 minutes and subsequent doses over 30 minutes. Patient must be monitored for one hour after the first dose of trastuzumab.
PACLItaxel protein-bound (ABRAXANE) bag NF 120 mg/m2 (Treatment Plan)
120 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 30 Minutes
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 11/21/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: trastuzumab 4 mg/kg IV Day 1, trastuzumab 2 mg/kg IV Day 8, 15, and 22,
PACLItaxel Protein Bound Particles 120 mg/m2 IV Day 1, 8, 15; CYCLE LENGTH: 28 days; COURSE: 1 cycle followed by
THERAPY: trastuzumab 2 mg/kg IV Day 1, 8, 15, 22, PACLItaxel Protein Bound Particiles 120 mg/m2 IV Day 1, 8, 15; CYCLE
LENGTH: 28 days; COURSE: until disease progression.
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]
11/7/2016 1:16:59 PM Page 4 of 35
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 100K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to trastuzumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient must be monitored for one hour after the first dose of trastuzumab. See Emergency Medications.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 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
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
trastuzumab (HERCEPTIN) 159 mg in sodium chloride 0.9 % 250 mL bag
159 mg (rounded from 158.8 mg = 2 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy. Give first dose over
60 minutes and subsequent doses over 30 minutes. Patient must be monitored for one hour after the first dose of trastuzumab.
PACLItaxel protein-bound (ABRAXANE) bag NF 120 mg/m2 (Treatment Plan)
120 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 30 Minutes
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]
11/7/2016 1:16:59 PM Page 5 of 35
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Day 22, Cycle 1 – Planned for 11/28/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: trastuzumab 4 mg/kg IV Day 1, trastuzumab 2 mg/kg IV Day 8, 15, and 22,
PACLItaxel Protein Bound Particles 120 mg/m2 IV Day 1, 8, 15; CYCLE LENGTH: 28 days; COURSE: 1 cycle followed by
THERAPY: trastuzumab 2 mg/kg IV Day 1, 8, 15, 22, PACLItaxel Protein Bound Particiles 120 mg/m2 IV Day 1, 8, 15; CYCLE
LENGTH: 28 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to trastuzumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient must be monitored for one hour after the first dose of trastuzumab. See Emergency Medications.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 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.
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
trastuzumab (HERCEPTIN) 159 mg in sodium chloride 0.9 % 250 mL bag
159 mg (rounded from 158.8 mg = 2 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy. Give first dose over
60 minutes and subsequent doses over 30 minutes. Patient must be monitored for one hour after the first dose of trastuzumab.
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]
11/7/2016 1:16:59 PM Page 6 of 35
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Cycle 2 – 12/5/2016 through 1/1/2017 (28 days), Planned
Day 1, Cycle 2 – Planned for 12/5/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: trastuzumab 4 mg/kg IV Day 1, trastuzumab 2 mg/kg IV Day 8, 15, and 22,
PACLItaxel Protein Bound Particles 120 mg/m2 IV Day 1, 8, 15; CYCLE LENGTH: 28 days; COURSE: 1 cycle followed by
THERAPY: trastuzumab 2 mg/kg IV Day 1, 8, 15, 22, PACLItaxel Protein Bound Particiles 120 mg/m2 IV Day 1, 8, 15; 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.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to trastuzumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient must be monitored for one hour after the first dose of trastuzumab. See Emergency Medications.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
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ZZtestonc,Andrew [2428787]
11/7/2016 1:16:59 PM Page 7 of 35
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
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
trastuzumab (HERCEPTIN) 159 mg in sodium chloride 0.9 % 250 mL bag
159 mg (rounded from 158.8 mg = 2 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy. Give first dose over
60 minutes and subsequent doses over 30 minutes. Patient must be monitored for one hour after the first dose of trastuzumab.
PACLItaxel protein-bound (ABRAXANE) bag NF 120 mg/m2 (Treatment Plan)
120 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 30 Minutes
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally); CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel Protein Bound Particles and
trastuzumab 90 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally); CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel Protein Bound Particles and
trastuzumab 90 minutes.
DAY 22 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: trastuzumab infusion for 60 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 Protein Bound
Particles and trastuzumab infusion for 90 minutes.
Day 8, Cycle 2 – Planned for 12/12/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: trastuzumab 4 mg/kg IV Day 1, trastuzumab 2 mg/kg IV Day 8, 15, and 22,
PACLItaxel Protein Bound Particles 120 mg/m2 IV Day 1, 8, 15; CYCLE LENGTH: 28 days; COURSE: 1 cycle followed by
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ZZtestonc,Andrew [2428787]
11/7/2016 1:16:59 PM Page 8 of 35
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

THERAPY: trastuzumab 2 mg/kg IV Day 1, 8, 15, 22, PACLItaxel Protein Bound Particiles 120 mg/m2 IV Day 1, 8, 15; CYCLE
LENGTH: 28 days; COURSE: until disease progression.
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 100K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to trastuzumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient must be monitored for one hour after the first dose of trastuzumab. See Emergency Medications.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 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
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
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ZZtestonc,Andrew [2428787]
11/7/2016 1:16:59 PM Page 9 of 35
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
trastuzumab (HERCEPTIN) 159 mg in sodium chloride 0.9 % 250 mL bag
159 mg (rounded from 158.8 mg = 2 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy. Give first dose over
60 minutes and subsequent doses over 30 minutes. Patient must be monitored for one hour after the first dose of trastuzumab.
PACLItaxel protein-bound (ABRAXANE) bag NF 120 mg/m2 (Treatment Plan)
120 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 30 Minutes
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 2 – Planned for 12/19/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: trastuzumab 4 mg/kg IV Day 1, trastuzumab 2 mg/kg IV Day 8, 15, and 22,
PACLItaxel Protein Bound Particles 120 mg/m2 IV Day 1, 8, 15; CYCLE LENGTH: 28 days; COURSE: 1 cycle followed by
THERAPY: trastuzumab 2 mg/kg IV Day 1, 8, 15, 22, PACLItaxel Protein Bound Particiles 120 mg/m2 IV Day 1, 8, 15; CYCLE
LENGTH: 28 days; COURSE: until disease progression.
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 100K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to trastuzumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient must be monitored for one hour after the first dose of trastuzumab. See Emergency Medications.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 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]
11/7/2016 1:16:59 PM Page 10 of 35
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
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
trastuzumab (HERCEPTIN) 159 mg in sodium chloride 0.9 % 250 mL bag
159 mg (rounded from 158.8 mg = 2 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy. Give first dose over
60 minutes and subsequent doses over 30 minutes. Patient must be monitored for one hour after the first dose of trastuzumab.
PACLItaxel protein-bound (ABRAXANE) bag NF 120 mg/m2 (Treatment Plan)
120 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 30 Minutes
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 12/26/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: trastuzumab 4 mg/kg IV Day 1, trastuzumab 2 mg/kg IV Day 8, 15, and 22,
PACLItaxel Protein Bound Particles 120 mg/m2 IV Day 1, 8, 15; CYCLE LENGTH: 28 days; COURSE: 1 cycle followed by
THERAPY: trastuzumab 2 mg/kg IV Day 1, 8, 15, 22, PACLItaxel Protein Bound Particiles 120 mg/m2 IV Day 1, 8, 15; CYCLE
LENGTH: 28 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to trastuzumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient must be monitored for one hour after the first dose of trastuzumab. See Emergency Medications.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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ZZtestonc,Andrew [2428787]
11/7/2016 1:16:59 PM Page 11 of 35
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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.
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
trastuzumab (HERCEPTIN) 159 mg in sodium chloride 0.9 % 250 mL bag
159 mg (rounded from 158.8 mg = 2 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy. Give first dose over
60 minutes and subsequent doses over 30 minutes. Patient must be monitored for one hour after the first dose of trastuzumab.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 – 1/2/2017 through 1/29/2017 (28 days), Planned
Day 1, Cycle 3 – Planned for 1/2/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: trastuzumab 4 mg/kg IV Day 1, trastuzumab 2 mg/kg IV Day 8, 15, and 22,
PACLItaxel Protein Bound Particles 120 mg/m2 IV Day 1, 8, 15; CYCLE LENGTH: 28 days; COURSE: 1 cycle followed by
THERAPY: trastuzumab 2 mg/kg IV Day 1, 8, 15, 22, PACLItaxel Protein Bound Particiles 120 mg/m2 IV Day 1, 8, 15; 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
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ZZtestonc,Andrew [2428787]
11/7/2016 1:16:59 PM Page 12 of 35
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

CBC WITHOUT DIFFERENTIAL
Expected-S+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.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to trastuzumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient must be monitored for one hour after the first dose of trastuzumab. See Emergency Medications.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 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
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
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ZZtestonc,Andrew [2428787]
11/7/2016 1:16:59 PM Page 13 of 35
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
trastuzumab (HERCEPTIN) 159 mg in sodium chloride 0.9 % 250 mL bag
159 mg (rounded from 158.8 mg = 2 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy. Give first dose over
60 minutes and subsequent doses over 30 minutes. Patient must be monitored for one hour after the first dose of trastuzumab.
PACLItaxel protein-bound (ABRAXANE) bag NF 120 mg/m2 (Treatment Plan)
120 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 30 Minutes
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally); CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel Protein Bound Particles and
trastuzumab 90 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally); CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel Protein Bound Particles and
trastuzumab 90 minutes.
DAY 22 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: trastuzumab infusion for 60 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 Protein Bound
Particles and trastuzumab infusion for 90 minutes.
Day 8, Cycle 3 – Planned for 1/9/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: trastuzumab 4 mg/kg IV Day 1, trastuzumab 2 mg/kg IV Day 8, 15, and 22,
PACLItaxel Protein Bound Particles 120 mg/m2 IV Day 1, 8, 15; CYCLE LENGTH: 28 days; COURSE: 1 cycle followed by
THERAPY: trastuzumab 2 mg/kg IV Day 1, 8, 15, 22, PACLItaxel Protein Bound Particiles 120 mg/m2 IV Day 1, 8, 15; CYCLE
LENGTH: 28 days; COURSE: until disease progression.
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 100K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
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ZZtestonc,Andrew [2428787]
11/7/2016 1:16:59 PM Page 14 of 35
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Hypersensitivity reaction to trastuzumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient must be monitored for one hour after the first dose of trastuzumab. See Emergency Medications.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 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
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
trastuzumab (HERCEPTIN) 159 mg in sodium chloride 0.9 % 250 mL bag
159 mg (rounded from 158.8 mg = 2 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy. Give first dose over
60 minutes and subsequent doses over 30 minutes. Patient must be monitored for one hour after the first dose of trastuzumab.
PACLItaxel protein-bound (ABRAXANE) bag NF 120 mg/m2 (Treatment Plan)
120 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 30 Minutes
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 1/16/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: trastuzumab 4 mg/kg IV Day 1, trastuzumab 2 mg/kg IV Day 8, 15, and 22,
PACLItaxel Protein Bound Particles 120 mg/m2 IV Day 1, 8, 15; CYCLE LENGTH: 28 days; COURSE: 1 cycle followed by
THERAPY: trastuzumab 2 mg/kg IV Day 1, 8, 15, 22, PACLItaxel Protein Bound Particiles 120 mg/m2 IV Day 1, 8, 15; CYCLE
LENGTH: 28 days; COURSE: until disease progression.
IV Access
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ZZtestonc,Andrew [2428787]
11/7/2016 1:16:59 PM Page 15 of 35
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 100K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to trastuzumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient must be monitored for one hour after the first dose of trastuzumab. See Emergency Medications.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 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
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
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ZZtestonc,Andrew [2428787]
11/7/2016 1:16:59 PM Page 16 of 35
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Medications
trastuzumab (HERCEPTIN) 159 mg in sodium chloride 0.9 % 250 mL bag
159 mg (rounded from 158.8 mg = 2 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy. Give first dose over
60 minutes and subsequent doses over 30 minutes. Patient must be monitored for one hour after the first dose of trastuzumab.
PACLItaxel protein-bound (ABRAXANE) bag NF 120 mg/m2 (Treatment Plan)
120 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 30 Minutes
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 1/23/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: trastuzumab 4 mg/kg IV Day 1, trastuzumab 2 mg/kg IV Day 8, 15, and 22,
PACLItaxel Protein Bound Particles 120 mg/m2 IV Day 1, 8, 15; CYCLE LENGTH: 28 days; COURSE: 1 cycle followed by
THERAPY: trastuzumab 2 mg/kg IV Day 1, 8, 15, 22, PACLItaxel Protein Bound Particiles 120 mg/m2 IV Day 1, 8, 15; CYCLE
LENGTH: 28 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to trastuzumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient must be monitored for one hour after the first dose of trastuzumab. See Emergency Medications.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 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.
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
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ZZtestonc,Andrew [2428787]
11/7/2016 1:16:59 PM Page 17 of 35
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
trastuzumab (HERCEPTIN) 159 mg in sodium chloride 0.9 % 250 mL bag
159 mg (rounded from 158.8 mg = 2 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy. Give first dose over
60 minutes and subsequent doses over 30 minutes. Patient must be monitored for one hour after the first dose of trastuzumab.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 – 1/30/2017 through 2/26/2017 (28 days), Planned
Day 1, Cycle 4 – Planned for 1/30/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: trastuzumab 4 mg/kg IV Day 1, trastuzumab 2 mg/kg IV Day 8, 15, and 22,
PACLItaxel Protein Bound Particles 120 mg/m2 IV Day 1, 8, 15; CYCLE LENGTH: 28 days; COURSE: 1 cycle followed by
THERAPY: trastuzumab 2 mg/kg IV Day 1, 8, 15, 22, PACLItaxel Protein Bound Particiles 120 mg/m2 IV Day 1, 8, 15; 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
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ZZtestonc,Andrew [2428787]
11/7/2016 1:16:59 PM Page 18 of 35
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to trastuzumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient must be monitored for one hour after the first dose of trastuzumab. See Emergency Medications.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 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
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
trastuzumab (HERCEPTIN) 159 mg in sodium chloride 0.9 % 250 mL bag
159 mg (rounded from 158.8 mg = 2 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy. Give first dose over
60 minutes and subsequent doses over 30 minutes. Patient must be monitored for one hour after the first dose of trastuzumab.
PACLItaxel protein-bound (ABRAXANE) bag NF 120 mg/m2 (Treatment Plan)
120 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 30 Minutes
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally); CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel Protein Bound Particles and
trastuzumab 90 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally); CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel Protein Bound Particles and
trastuzumab 90 minutes.
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ZZtestonc,Andrew [2428787]
11/7/2016 1:16:59 PM Page 19 of 35
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DAY 22 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: trastuzumab infusion for 60 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 Protein Bound
Particles and trastuzumab infusion for 90 minutes.
Day 8, Cycle 4 – Planned for 2/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: trastuzumab 4 mg/kg IV Day 1, trastuzumab 2 mg/kg IV Day 8, 15, and 22,
PACLItaxel Protein Bound Particles 120 mg/m2 IV Day 1, 8, 15; CYCLE LENGTH: 28 days; COURSE: 1 cycle followed by
THERAPY: trastuzumab 2 mg/kg IV Day 1, 8, 15, 22, PACLItaxel Protein Bound Particiles 120 mg/m2 IV Day 1, 8, 15; CYCLE
LENGTH: 28 days; COURSE: until disease progression.
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 100K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to trastuzumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient must be monitored for one hour after the first dose of trastuzumab. See Emergency Medications.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 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
ondansetron (ZOFRAN) tab 8 mg
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ZZtestonc,Andrew [2428787]
11/7/2016 1:16:59 PM Page 20 of 35
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
trastuzumab (HERCEPTIN) 159 mg in sodium chloride 0.9 % 250 mL bag
159 mg (rounded from 158.8 mg = 2 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy. Give first dose over
60 minutes and subsequent doses over 30 minutes. Patient must be monitored for one hour after the first dose of trastuzumab.
PACLItaxel protein-bound (ABRAXANE) bag NF 120 mg/m2 (Treatment Plan)
120 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 30 Minutes
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 2/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: trastuzumab 4 mg/kg IV Day 1, trastuzumab 2 mg/kg IV Day 8, 15, and 22,
PACLItaxel Protein Bound Particles 120 mg/m2 IV Day 1, 8, 15; CYCLE LENGTH: 28 days; COURSE: 1 cycle followed by
THERAPY: trastuzumab 2 mg/kg IV Day 1, 8, 15, 22, PACLItaxel Protein Bound Particiles 120 mg/m2 IV Day 1, 8, 15; CYCLE
LENGTH: 28 days; COURSE: until disease progression.
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 100K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
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ZZtestonc,Andrew [2428787]
11/7/2016 1:16:59 PM Page 21 of 35
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Hypersensitivity reaction to trastuzumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient must be monitored for one hour after the first dose of trastuzumab. See Emergency Medications.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 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
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
trastuzumab (HERCEPTIN) 159 mg in sodium chloride 0.9 % 250 mL bag
159 mg (rounded from 158.8 mg = 2 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy. Give first dose over
60 minutes and subsequent doses over 30 minutes. Patient must be monitored for one hour after the first dose of trastuzumab.
PACLItaxel protein-bound (ABRAXANE) bag NF 120 mg/m2 (Treatment Plan)
120 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 30 Minutes
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 2/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: trastuzumab 4 mg/kg IV Day 1, trastuzumab 2 mg/kg IV Day 8, 15, and 22,
PACLItaxel Protein Bound Particles 120 mg/m2 IV Day 1, 8, 15; CYCLE LENGTH: 28 days; COURSE: 1 cycle followed by
THERAPY: trastuzumab 2 mg/kg IV Day 1, 8, 15, 22, PACLItaxel Protein Bound Particiles 120 mg/m2 IV Day 1, 8, 15; CYCLE
LENGTH: 28 days; COURSE: until disease progression.
IV Access
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ZZtestonc,Andrew [2428787]
11/7/2016 1:16:59 PM Page 22 of 35
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.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to trastuzumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient must be monitored for one hour after the first dose of trastuzumab. See Emergency Medications.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 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.
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
trastuzumab (HERCEPTIN) 159 mg in sodium chloride 0.9 % 250 mL bag
159 mg (rounded from 158.8 mg = 2 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy. Give first dose over
60 minutes and subsequent doses over 30 minutes. Patient must be monitored for one hour after the first dose of trastuzumab.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 – 2/27/2017 through 3/26/2017 (28 days), Planned
Day 1, Cycle 5 – Planned for 2/27/2017
Treatment Plan Information
Treatment Plan Summary
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ZZtestonc,Andrew [2428787]
11/7/2016 1:16:59 PM Page 23 of 35
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: trastuzumab 4 mg/kg IV Day 1, trastuzumab 2 mg/kg IV Day 8, 15, and 22,
PACLItaxel Protein Bound Particles 120 mg/m2 IV Day 1, 8, 15; CYCLE LENGTH: 28 days; COURSE: 1 cycle followed by
THERAPY: trastuzumab 2 mg/kg IV Day 1, 8, 15, 22, PACLItaxel Protein Bound Particiles 120 mg/m2 IV Day 1, 8, 15; 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.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to trastuzumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient must be monitored for one hour after the first dose of trastuzumab. See Emergency Medications.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 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]
11/7/2016 1:16:59 PM Page 24 of 35
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
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
trastuzumab (HERCEPTIN) 159 mg in sodium chloride 0.9 % 250 mL bag
159 mg (rounded from 158.8 mg = 2 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy. Give first dose over
60 minutes and subsequent doses over 30 minutes. Patient must be monitored for one hour after the first dose of trastuzumab.
PACLItaxel protein-bound (ABRAXANE) bag NF 120 mg/m2 (Treatment Plan)
120 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 30 Minutes
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally); CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel Protein Bound Particles and
trastuzumab 90 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally); CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel Protein Bound Particles and
trastuzumab 90 minutes.
DAY 22 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: trastuzumab infusion for 60 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 Protein Bound
Particles and trastuzumab infusion for 90 minutes.
Day 8, Cycle 5 – Planned for 3/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: trastuzumab 4 mg/kg IV Day 1, trastuzumab 2 mg/kg IV Day 8, 15, and 22,
PACLItaxel Protein Bound Particles 120 mg/m2 IV Day 1, 8, 15; CYCLE LENGTH: 28 days; COURSE: 1 cycle followed by
THERAPY: trastuzumab 2 mg/kg IV Day 1, 8, 15, 22, PACLItaxel Protein Bound Particiles 120 mg/m2 IV Day 1, 8, 15; CYCLE
LENGTH: 28 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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ZZtestonc,Andrew [2428787]
11/7/2016 1:16:59 PM Page 25 of 35
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

CBC WITHOUT DIFFERENTIAL
Expected-S+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 100K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to trastuzumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient must be monitored for one hour after the first dose of trastuzumab. See Emergency Medications.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 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
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
trastuzumab (HERCEPTIN) 159 mg in sodium chloride 0.9 % 250 mL bag
159 mg (rounded from 158.8 mg = 2 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy. Give first dose over
60 minutes and subsequent doses over 30 minutes. Patient must be monitored for one hour after the first dose of trastuzumab.
PACLItaxel protein-bound (ABRAXANE) bag NF 120 mg/m2 (Treatment Plan)
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ZZtestonc,Andrew [2428787]
11/7/2016 1:16:59 PM Page 26 of 35
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

120 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 30 Minutes
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 3/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: trastuzumab 4 mg/kg IV Day 1, trastuzumab 2 mg/kg IV Day 8, 15, and 22,
PACLItaxel Protein Bound Particles 120 mg/m2 IV Day 1, 8, 15; CYCLE LENGTH: 28 days; COURSE: 1 cycle followed by
THERAPY: trastuzumab 2 mg/kg IV Day 1, 8, 15, 22, PACLItaxel Protein Bound Particiles 120 mg/m2 IV Day 1, 8, 15; CYCLE
LENGTH: 28 days; COURSE: until disease progression.
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 100K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to trastuzumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient must be monitored for one hour after the first dose of trastuzumab. See Emergency Medications.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 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
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
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ZZtestonc,Andrew [2428787]
11/7/2016 1:16:59 PM Page 27 of 35
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
trastuzumab (HERCEPTIN) 159 mg in sodium chloride 0.9 % 250 mL bag
159 mg (rounded from 158.8 mg = 2 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy. Give first dose over
60 minutes and subsequent doses over 30 minutes. Patient must be monitored for one hour after the first dose of trastuzumab.
PACLItaxel protein-bound (ABRAXANE) bag NF 120 mg/m2 (Treatment Plan)
120 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 30 Minutes
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 3/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: trastuzumab 4 mg/kg IV Day 1, trastuzumab 2 mg/kg IV Day 8, 15, and 22,
PACLItaxel Protein Bound Particles 120 mg/m2 IV Day 1, 8, 15; CYCLE LENGTH: 28 days; COURSE: 1 cycle followed by
THERAPY: trastuzumab 2 mg/kg IV Day 1, 8, 15, 22, PACLItaxel Protein Bound Particiles 120 mg/m2 IV Day 1, 8, 15; CYCLE
LENGTH: 28 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to trastuzumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient must be monitored for one hour after the first dose of trastuzumab. See Emergency Medications.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 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
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ZZtestonc,Andrew [2428787]
11/7/2016 1:16:59 PM Page 28 of 35
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Emergency Medications
diphenhydramine (BENADRYL) injection 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
trastuzumab (HERCEPTIN) 159 mg in sodium chloride 0.9 % 250 mL bag
159 mg (rounded from 158.8 mg = 2 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy. Give first dose over
60 minutes and subsequent doses over 30 minutes. Patient must be monitored for one hour after the first dose of trastuzumab.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 6 – 3/27/2017 through 4/23/2017 (28 days), Planned
Day 1, Cycle 6 – Planned for 3/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: trastuzumab 4 mg/kg IV Day 1, trastuzumab 2 mg/kg IV Day 8, 15, and 22,
PACLItaxel Protein Bound Particles 120 mg/m2 IV Day 1, 8, 15; CYCLE LENGTH: 28 days; COURSE: 1 cycle followed by
THERAPY: trastuzumab 2 mg/kg IV Day 1, 8, 15, 22, PACLItaxel Protein Bound Particiles 120 mg/m2 IV Day 1, 8, 15; 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
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ZZtestonc,Andrew [2428787]
11/7/2016 1:16:59 PM Page 29 of 35
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to trastuzumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient must be monitored for one hour after the first dose of trastuzumab. See Emergency Medications.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 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
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
trastuzumab (HERCEPTIN) 159 mg in sodium chloride 0.9 % 250 mL bag
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ZZtestonc,Andrew [2428787]
11/7/2016 1:16:59 PM Page 30 of 35
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

159 mg (rounded from 158.8 mg = 2 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy. Give first dose over
60 minutes and subsequent doses over 30 minutes. Patient must be monitored for one hour after the first dose of trastuzumab.
PACLItaxel protein-bound (ABRAXANE) bag NF 120 mg/m2 (Treatment Plan)
120 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 30 Minutes
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally); CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel Protein Bound Particles and
trastuzumab 90 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally); CHEMOTHERAPY ROOM APPOINTMENT: PACLItaxel Protein Bound Particles and
trastuzumab 90 minutes.
DAY 22 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: trastuzumab infusion for 60 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 Protein Bound
Particles and trastuzumab infusion for 90 minutes.
Day 8, Cycle 6 – Planned for 4/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: trastuzumab 4 mg/kg IV Day 1, trastuzumab 2 mg/kg IV Day 8, 15, and 22,
PACLItaxel Protein Bound Particles 120 mg/m2 IV Day 1, 8, 15; CYCLE LENGTH: 28 days; COURSE: 1 cycle followed by
THERAPY: trastuzumab 2 mg/kg IV Day 1, 8, 15, 22, PACLItaxel Protein Bound Particiles 120 mg/m2 IV Day 1, 8, 15; CYCLE
LENGTH: 28 days; COURSE: until disease progression.
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 100K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to trastuzumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient must be monitored for one hour after the first dose of trastuzumab. See Emergency Medications.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
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ZZtestonc,Andrew [2428787]
11/7/2016 1:16:59 PM Page 31 of 35
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
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
trastuzumab (HERCEPTIN) 159 mg in sodium chloride 0.9 % 250 mL bag
159 mg (rounded from 158.8 mg = 2 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy. Give first dose over
60 minutes and subsequent doses over 30 minutes. Patient must be monitored for one hour after the first dose of trastuzumab.
PACLItaxel protein-bound (ABRAXANE) bag NF 120 mg/m2 (Treatment Plan)
120 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 30 Minutes
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 4/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: trastuzumab 4 mg/kg IV Day 1, trastuzumab 2 mg/kg IV Day 8, 15, and 22,
PACLItaxel Protein Bound Particles 120 mg/m2 IV Day 1, 8, 15; CYCLE LENGTH: 28 days; COURSE: 1 cycle followed by
THERAPY: trastuzumab 2 mg/kg IV Day 1, 8, 15, 22, PACLItaxel Protein Bound Particiles 120 mg/m2 IV Day 1, 8, 15; CYCLE
LENGTH: 28 days; COURSE: until disease progression.
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
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ZZtestonc,Andrew [2428787]
11/7/2016 1:16:59 PM Page 32 of 35
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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 100K/µL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to trastuzumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient must be monitored for one hour after the first dose of trastuzumab. See Emergency Medications.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 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
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
trastuzumab (HERCEPTIN) 159 mg in sodium chloride 0.9 % 250 mL bag
159 mg (rounded from 158.8 mg = 2 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy. Give first dose over
60 minutes and subsequent doses over 30 minutes. Patient must be monitored for one hour after the first dose of trastuzumab.
PACLItaxel protein-bound (ABRAXANE) bag NF 120 mg/m2 (Treatment Plan)
120 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 30 Minutes
Follow-Up
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ZZtestonc,Andrew [2428787]
11/7/2016 1:16:59 PM Page 33 of 35
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.
Day 22, Cycle 6 – Planned for 4/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: trastuzumab 4 mg/kg IV Day 1, trastuzumab 2 mg/kg IV Day 8, 15, and 22,
PACLItaxel Protein Bound Particles 120 mg/m2 IV Day 1, 8, 15; CYCLE LENGTH: 28 days; COURSE: 1 cycle followed by
THERAPY: trastuzumab 2 mg/kg IV Day 1, 8, 15, 22, PACLItaxel Protein Bound Particiles 120 mg/m2 IV Day 1, 8, 15; CYCLE
LENGTH: 28 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to trastuzumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. Patient must be monitored for one hour after the first dose of trastuzumab. See Emergency Medications.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 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.
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
trastuzumab (HERCEPTIN) 159 mg in sodium chloride 0.9 % 250 mL bag
159 mg (rounded from 158.8 mg = 2 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy. Give first dose over
60 minutes and subsequent doses over 30 minutes. Patient must be monitored for one hour after the first dose of trastuzumab.
Follow-Up
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ZZtestonc,Andrew [2428787]
11/7/2016 1:16:59 PM Page 34 of 35
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.
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ZZtestonc,Andrew [2428787]
11/7/2016 1:16:59 PM Page 35 of 35
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org