/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-96618-en.cckm

201611312

page

100

UWHC,UWMF,

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

CSC Breast Trastuzumab (21D1), Vinorelbine (21D1,8) VER 10-3-16 (HL 568)

CSC Breast Trastuzumab (21D1), Vinorelbine (21D1,8) VER 10-3-16 (HL 568) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Breast


CSC BREAST TRASTUZUMAB(21D:1)/ VINORELBINE(21D:1,8) 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 (Advanced); THERAPY: trastuzumab 8 mg/kg IV Day 1, vinorelbine 25 to 30 mg/m2 IV Day 1 and 8; CYCLE
LENGTH: 21 days; COURSE: 1 cycle followed by THERAPY: trastuzumab 6 mg/kg IV Day 1, vinorelbine 25 to 30 mg/m2 IV Day 1
and 8; CYCLE LENGTH: 21 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 11/27/2016 (21 days), Planned
Day 1, Cycle 1 – Planned for 11/7/2016
Treatment Plan Information
Reference Information (1)
BREAST CANCER: Papaldo, P., et al. Ann Oncol 2006;17:630-36.
Treatment Plan Summary
DISEASE: Breast (Advanced); THERAPY: trastuzumab 8 mg/kg IV Day 1, vinorelbine 25 to 30 mg/m2 IV Day 1 and 8; CYCLE
LENGTH: 21 days; COURSE: 1 cycle followed by THERAPY: trastuzumab 6 mg/kg IV Day 1, vinorelbine 25 to 30 mg/m2 IV Day 1
and 8; CYCLE LENGTH: 21 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/7/2016 1:22:57 PM Page 1 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Total Bilirubin, AST.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL or Total
Bilirubin greater than or equal to 1.5 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.
sodium chloride 0.9 % infusion
at 1,000 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
Vinorelbine should be followed by sodium chloride 0.9% 500mL IV when administered through a peripheral IV to prevent phlebitis.
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) 635 mg in sodium chloride 0.9 % 250 mL bag
635 mg (rounded from 635.2 mg = 8 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. Administer over 90
minutes. Patient must be monitored for one hour after the first dose of trastuzumab.
vinorelbine (NAVELBINE) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
Vinorelbine should be followed by sodium chloride 0.9% 500 mL IV when administered through a peripheral IV to prevent phlebitis.
Follow-Up
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ZZtestonc,Andrew [2428787]
11/7/2016 1:22:57 PM Page 2 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: vinorelbine for 90 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine,
Calcium, Total Bilirubin, AST, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: vinorelbine and trastuzumab for
90 minutes.
Day 8, Cycle 1 – Planned for 11/14/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast (Advanced); THERAPY: trastuzumab 8 mg/kg IV Day 1, vinorelbine 25 to 30 mg/m2 IV Day 1 and 8; CYCLE
LENGTH: 21 days; COURSE: 1 cycle followed by THERAPY: trastuzumab 6 mg/kg IV Day 1, vinorelbine 25 to 30 mg/m2 IV Day 1
and 8; CYCLE LENGTH: 21 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
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.
sodium chloride 0.9 % infusion
at 1,000 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
Vinorelbine should be followed by sodium chloride 0.9% 500mL IV when administered through a peripheral IV to prevent phlebitis.
Treatment Medications
vinorelbine (NAVELBINE) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
Vinorelbine should be followed by sodium chloride 0.9% 500 mL IV when administered through a peripheral IV to prevent phlebitis.
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ZZtestonc,Andrew [2428787]
11/7/2016 1:22:57 PM Page 3 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Follow-Up
VERIFY APPOINTMENTS
Verify Day 22 appointment(s) have been scheduled: (Day 1 of next cycle) RETURN TO CLINIC for appointment with provider;
LABS: CBC, ANC (DIFF if to be done locally), Creatinine, Calcium, Total Bilirubin, AST, Alkaline Phosphatase; CHEMOTHERAPY
ROOM APPOINTMENT: vinorelbine and trastuzumab for 90 minutes.
Cycle 2 – 11/28/2016 through 12/18/2016 (21 days), Planned
Day 1, Cycle 2 – Planned for 11/28/2016
Treatment Plan Information
Reference Information (1)
BREAST CANCER: Papaldo, P., et al. Ann Oncol 2006;17:630-36.
Treatment Plan Summary
DISEASE: Breast (Advanced); THERAPY: trastuzumab 8 mg/kg IV Day 1, vinorelbine 25 to 30 mg/m2 IV Day 1 and 8; CYCLE
LENGTH: 21 days; COURSE: 1 cycle followed by THERAPY: trastuzumab 6 mg/kg IV Day 1, vinorelbine 25 to 30 mg/m2 IV Day 1
and 8; CYCLE LENGTH: 21 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+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Total Bilirubin, AST.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL or Total
Bilirubin greater than or equal to 1.5 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.
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ZZtestonc,Andrew [2428787]
11/7/2016 1:22:57 PM Page 4 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
sodium chloride 0.9 % infusion
at 1,000 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
Vinorelbine should be followed by sodium chloride 0.9% 500mL IV when administered through a peripheral IV to prevent phlebitis.
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) 476 mg in sodium chloride 0.9 % 250 mL bag
476 mg (rounded from 476.4 mg = 6 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care. See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy. Patient must be
monitored for one hour after the first dose of trastuzumab.
vinorelbine (NAVELBINE) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
Vinorelbine should be followed by sodium chloride 0.9% 500 mL IV when administered through a peripheral IV to prevent phlebitis.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: vinorelbine for 90 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Creatinine, Calcium, Total Bilirubin, AST, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: vinorelbine and
trastuzumab for 90 minutes.
Day 8, Cycle 2 – Planned for 12/5/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast (Advanced); THERAPY: trastuzumab 8 mg/kg IV Day 1, vinorelbine 25 to 30 mg/m2 IV Day 1 and 8; CYCLE
LENGTH: 21 days; COURSE: 1 cycle followed by THERAPY: trastuzumab 6 mg/kg IV Day 1, vinorelbine 25 to 30 mg/m2 IV Day 1
and 8; CYCLE LENGTH: 21 days; COURSE: until disease progression.
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ZZtestonc,Andrew [2428787]
11/7/2016 1:22:57 PM Page 5 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
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
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.
sodium chloride 0.9 % infusion
at 1,000 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
Vinorelbine should be followed by sodium chloride 0.9% 500mL IV when administered through a peripheral IV to prevent phlebitis.
Treatment Medications
vinorelbine (NAVELBINE) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
Vinorelbine should be followed by sodium chloride 0.9% 500 mL IV when administered through a peripheral IV to prevent phlebitis.
Follow-Up
VERIFY APPOINTMENTS
Verify Day 22 appointment(s) have been scheduled: (Day 1 of next cycle) RETURN TO CLINIC for appointment with provider;
LABS: CBC, ANC (DIFF if to be done locally), Creatinine, Calcium, Total Bilirubin, AST, Alkaline Phosphatase; CHEMOTHERAPY
ROOM APPOINTMENT: vinorelbine and trastuzumab for 90 minutes.
Cycle 3 – 12/19/2016 through 1/8/2017 (21 days), Planned
Day 1, Cycle 3 – Planned for 12/19/2016
Treatment Plan Information
Reference Information (1)
BREAST CANCER: Papaldo, P., et al. Ann Oncol 2006;17:630-36.
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ZZtestonc,Andrew [2428787]
11/7/2016 1:22:57 PM Page 6 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Breast (Advanced); THERAPY: trastuzumab 8 mg/kg IV Day 1, vinorelbine 25 to 30 mg/m2 IV Day 1 and 8; CYCLE
LENGTH: 21 days; COURSE: 1 cycle followed by THERAPY: trastuzumab 6 mg/kg IV Day 1, vinorelbine 25 to 30 mg/m2 IV Day 1
and 8; CYCLE LENGTH: 21 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+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Total Bilirubin, AST.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL or Total
Bilirubin greater than or equal to 1.5 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
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ZZtestonc,Andrew [2428787]
11/7/2016 1:22:57 PM Page 7 of 18
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.
sodium chloride 0.9 % infusion
at 1,000 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
Vinorelbine should be followed by sodium chloride 0.9% 500mL IV when administered through a peripheral IV to prevent phlebitis.
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) 476 mg in sodium chloride 0.9 % 250 mL bag
476 mg (rounded from 476.4 mg = 6 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care. See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy. Patient must be
monitored for one hour after the first dose of trastuzumab.
vinorelbine (NAVELBINE) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
Vinorelbine should be followed by sodium chloride 0.9% 500 mL IV when administered through a peripheral IV to prevent phlebitis.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: vinorelbine for 90 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Creatinine, Calcium, Total Bilirubin, AST, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: vinorelbine and
trastuzumab for 90 minutes.
Day 8, Cycle 3 – Planned for 12/26/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast (Advanced); THERAPY: trastuzumab 8 mg/kg IV Day 1, vinorelbine 25 to 30 mg/m2 IV Day 1 and 8; CYCLE
LENGTH: 21 days; COURSE: 1 cycle followed by THERAPY: trastuzumab 6 mg/kg IV Day 1, vinorelbine 25 to 30 mg/m2 IV Day 1
and 8; CYCLE LENGTH: 21 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 1:22:57 PM Page 8 of 18
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
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.
sodium chloride 0.9 % infusion
at 1,000 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
Vinorelbine should be followed by sodium chloride 0.9% 500mL IV when administered through a peripheral IV to prevent phlebitis.
Treatment Medications
vinorelbine (NAVELBINE) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
Vinorelbine should be followed by sodium chloride 0.9% 500 mL IV when administered through a peripheral IV to prevent phlebitis.
Follow-Up
VERIFY APPOINTMENTS
Verify Day 22 appointment(s) have been scheduled: (Day 1 of next cycle) RETURN TO CLINIC for appointment with provider;
LABS: CBC, ANC (DIFF if to be done locally), Creatinine, Calcium, Total Bilirubin, AST, Alkaline Phosphatase; CHEMOTHERAPY
ROOM APPOINTMENT: vinorelbine and trastuzumab for 90 minutes.
Cycle 4 – 1/9/2017 through 1/29/2017 (21 days), Planned
Day 1, Cycle 4 – Planned for 1/9/2017
Treatment Plan Information
Reference Information (1)
BREAST CANCER: Papaldo, P., et al. Ann Oncol 2006;17:630-36.
Treatment Plan Summary
DISEASE: Breast (Advanced); THERAPY: trastuzumab 8 mg/kg IV Day 1, vinorelbine 25 to 30 mg/m2 IV Day 1 and 8; CYCLE
LENGTH: 21 days; COURSE: 1 cycle followed by THERAPY: trastuzumab 6 mg/kg IV Day 1, vinorelbine 25 to 30 mg/m2 IV Day 1
and 8; CYCLE LENGTH: 21 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/7/2016 1:22:57 PM Page 9 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Total Bilirubin, AST.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL or Total
Bilirubin greater than or equal to 1.5 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.
sodium chloride 0.9 % infusion
at 1,000 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
Vinorelbine should be followed by sodium chloride 0.9% 500mL IV when administered through a peripheral IV to prevent phlebitis.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
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ZZtestonc,Andrew [2428787]
11/7/2016 1:22:57 PM Page 10 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
trastuzumab (HERCEPTIN) 476 mg in sodium chloride 0.9 % 250 mL bag
476 mg (rounded from 476.4 mg = 6 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care. See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy. Patient must be
monitored for one hour after the first dose of trastuzumab.
vinorelbine (NAVELBINE) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
Vinorelbine should be followed by sodium chloride 0.9% 500 mL IV when administered through a peripheral IV to prevent phlebitis.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: vinorelbine for 90 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Creatinine, Calcium, Total Bilirubin, AST, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: vinorelbine and
trastuzumab for 90 minutes.
Day 8, Cycle 4 – Planned for 1/16/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast (Advanced); THERAPY: trastuzumab 8 mg/kg IV Day 1, vinorelbine 25 to 30 mg/m2 IV Day 1 and 8; CYCLE
LENGTH: 21 days; COURSE: 1 cycle followed by THERAPY: trastuzumab 6 mg/kg IV Day 1, vinorelbine 25 to 30 mg/m2 IV Day 1
and 8; CYCLE LENGTH: 21 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
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 1:22:57 PM Page 11 of 18
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.
sodium chloride 0.9 % infusion
at 1,000 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
Vinorelbine should be followed by sodium chloride 0.9% 500mL IV when administered through a peripheral IV to prevent phlebitis.
Treatment Medications
vinorelbine (NAVELBINE) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
Vinorelbine should be followed by sodium chloride 0.9% 500 mL IV when administered through a peripheral IV to prevent phlebitis.
Follow-Up
VERIFY APPOINTMENTS
Verify Day 22 appointment(s) have been scheduled: (Day 1 of next cycle) RETURN TO CLINIC for appointment with provider;
LABS: CBC, ANC (DIFF if to be done locally), Creatinine, Calcium, Total Bilirubin, AST, Alkaline Phosphatase; CHEMOTHERAPY
ROOM APPOINTMENT: vinorelbine and trastuzumab for 90 minutes.
Cycle 5 – 1/30/2017 through 2/19/2017 (21 days), Planned
Day 1, Cycle 5 – Planned for 1/30/2017
Treatment Plan Information
Reference Information (1)
BREAST CANCER: Papaldo, P., et al. Ann Oncol 2006;17:630-36.
Treatment Plan Summary
DISEASE: Breast (Advanced); THERAPY: trastuzumab 8 mg/kg IV Day 1, vinorelbine 25 to 30 mg/m2 IV Day 1 and 8; CYCLE
LENGTH: 21 days; COURSE: 1 cycle followed by THERAPY: trastuzumab 6 mg/kg IV Day 1, vinorelbine 25 to 30 mg/m2 IV Day 1
and 8; CYCLE LENGTH: 21 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+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
CALCIUM
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ZZtestonc,Andrew [2428787]
11/7/2016 1:22:57 PM Page 12 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Total Bilirubin, AST.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL or Total
Bilirubin greater than or equal to 1.5 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.
sodium chloride 0.9 % infusion
at 1,000 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
Vinorelbine should be followed by sodium chloride 0.9% 500mL IV when administered through a peripheral IV to prevent phlebitis.
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) 476 mg in sodium chloride 0.9 % 250 mL bag
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ZZtestonc,Andrew [2428787]
11/7/2016 1:22:57 PM Page 13 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

476 mg (rounded from 476.4 mg = 6 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care. See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy. Patient must be
monitored for one hour after the first dose of trastuzumab.
vinorelbine (NAVELBINE) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
Vinorelbine should be followed by sodium chloride 0.9% 500 mL IV when administered through a peripheral IV to prevent phlebitis.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: vinorelbine for 90 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Creatinine, Calcium, Total Bilirubin, AST, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: vinorelbine and
trastuzumab for 90 minutes.
Day 8, Cycle 5 – Planned for 2/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast (Advanced); THERAPY: trastuzumab 8 mg/kg IV Day 1, vinorelbine 25 to 30 mg/m2 IV Day 1 and 8; CYCLE
LENGTH: 21 days; COURSE: 1 cycle followed by THERAPY: trastuzumab 6 mg/kg IV Day 1, vinorelbine 25 to 30 mg/m2 IV Day 1
and 8; CYCLE LENGTH: 21 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
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.
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ZZtestonc,Andrew [2428787]
11/7/2016 1:22:57 PM Page 14 of 18
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 1,000 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
Vinorelbine should be followed by sodium chloride 0.9% 500mL IV when administered through a peripheral IV to prevent phlebitis.
Treatment Medications
vinorelbine (NAVELBINE) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
Vinorelbine should be followed by sodium chloride 0.9% 500 mL IV when administered through a peripheral IV to prevent phlebitis.
Follow-Up
VERIFY APPOINTMENTS
Verify Day 22 appointment(s) have been scheduled: (Day 1 of next cycle) RETURN TO CLINIC for appointment with provider;
LABS: CBC, ANC (DIFF if to be done locally), Creatinine, Calcium, Total Bilirubin, AST, Alkaline Phosphatase; CHEMOTHERAPY
ROOM APPOINTMENT: vinorelbine and trastuzumab for 90 minutes.
Cycle 6 – 2/20/2017 through 3/12/2017 (21 days), Planned
Day 1, Cycle 6 – Planned for 2/20/2017
Treatment Plan Information
Reference Information (1)
BREAST CANCER: Papaldo, P., et al. Ann Oncol 2006;17:630-36.
Treatment Plan Summary
DISEASE: Breast (Advanced); THERAPY: trastuzumab 8 mg/kg IV Day 1, vinorelbine 25 to 30 mg/m2 IV Day 1 and 8; CYCLE
LENGTH: 21 days; COURSE: 1 cycle followed by THERAPY: trastuzumab 6 mg/kg IV Day 1, vinorelbine 25 to 30 mg/m2 IV Day 1
and 8; CYCLE LENGTH: 21 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+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Total Bilirubin, AST.
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ZZtestonc,Andrew [2428787]
11/7/2016 1:22:57 PM Page 15 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL or Total
Bilirubin greater than or equal to 1.5 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.
sodium chloride 0.9 % infusion
at 1,000 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
Vinorelbine should be followed by sodium chloride 0.9% 500mL IV when administered through a peripheral IV to prevent phlebitis.
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) 476 mg in sodium chloride 0.9 % 250 mL bag
476 mg (rounded from 476.4 mg = 6 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize
emergency care. See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy. Patient must be
monitored for one hour after the first dose of trastuzumab.
vinorelbine (NAVELBINE) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
Vinorelbine should be followed by sodium chloride 0.9% 500 mL IV when administered through a peripheral IV to prevent phlebitis.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: vinorelbine for 90 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Creatinine, Calcium, Total Bilirubin, AST, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: vinorelbine and
trastuzumab for 90 minutes.
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ZZtestonc,Andrew [2428787]
11/7/2016 1:22:57 PM Page 16 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Day 8, Cycle 6 – Planned for 2/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast (Advanced); THERAPY: trastuzumab 8 mg/kg IV Day 1, vinorelbine 25 to 30 mg/m2 IV Day 1 and 8; CYCLE
LENGTH: 21 days; COURSE: 1 cycle followed by THERAPY: trastuzumab 6 mg/kg IV Day 1, vinorelbine 25 to 30 mg/m2 IV Day 1
and 8; CYCLE LENGTH: 21 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
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.
sodium chloride 0.9 % infusion
at 1,000 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
Vinorelbine should be followed by sodium chloride 0.9% 500mL IV when administered through a peripheral IV to prevent phlebitis.
Treatment Medications
vinorelbine (NAVELBINE) in sodium chloride 0.9 % 50 mL bag
Intravenous, ONCE, 1 dose Starting when released
Vinorelbine should be followed by sodium chloride 0.9% 500 mL IV when administered through a peripheral IV to prevent phlebitis.
Follow-Up
VERIFY APPOINTMENTS
Verify Day 22 appointment(s) have been scheduled: (Day 1 of next cycle) RETURN TO CLINIC for appointment with provider;
LABS: CBC, ANC (DIFF if to be done locally), Creatinine, Calcium, Total Bilirubin, AST, Alkaline Phosphatase; CHEMOTHERAPY
ROOM APPOINTMENT: vinorelbine and trastuzumab for 90 minutes.
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ZZtestonc,Andrew [2428787]
11/7/2016 1:22:57 PM Page 17 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

ZZtestonc,Andrew [2428787]
11/7/2016 1:22:57 PM Page 18 of 18
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org