/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-96619-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 (42D1,22) VER 10-3-16 (HL 671)

CSC Breast Trastuzumab (42D1,22) VER 10-3-16 (HL 671) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Breast


CSC BREAST TRASTUZUMAB(42D:1,22) 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 (Adjuvant/Advanced); THERAPY: trastuzumab 8mg/kg IV Loading Dose Cycle 1 Day 1, followed by
trastuzumab 6mg/kg IV every 3 weeks (Day 1 and Day 22 of all subsequent cycles); CYCLE LENGTH: 42 days; COURSE: 9 cycles
(one year of therapy = 18 doses) for adjuvant or until disease progression for advanced.
Consent
Verify Consent
Verify informed consent has been obtained.
Cycle 1 – 11/7/2016 through 12/18/2016 (42 days), Planned
Day 1, Cycle 1 – Planned for 11/7/2016
Treatment Plan Information
Reference Information (1)
BREAST CANCER: Leyland-Jones B, et al. J Clin Oncol 2003;21:3965-71.
Treatment Plan Summary
DISEASE: Breast Cancer (Adjuvant/Advanced); THERAPY: trastuzumab 8mg/kg IV Loading Dose Cycle 1 Day 1, followed by
trastuzumab 6mg/kg IV every 3 weeks (Day 1 and Day 22 of all subsequent cycles); CYCLE LENGTH: 42 days; COURSE: 9 cycles
(one year of therapy = 18 doses) for adjuvant or until disease progression for advanced.
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.
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.
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ZZtestonc,Andrew [2428787]
11/7/2016 1:24:30 PM Page 1 of 21
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) 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
Give first dose over 90 minutes and subsequent doses over 30 minutes. Hypersensitivity risk. For first and second dose, patient
should be treated in a location to optimize emergency care. See Emergency Medications. Patient must be monitored for one hour
after the first dose of trastuzumab. Trastuzumab should be given prior to any chemotherapy.
Follow-Up
DAY 22 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: trastuzumab for 90 minutes.
DAY 43 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; CHEMOTHERAPY ROOM APPOINTMENT: trastuzumab
for 30 minutes.
Day 22, Cycle 1 – Planned for 11/28/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Adjuvant/Advanced); THERAPY: trastuzumab 8mg/kg IV Loading Dose Cycle 1 Day 1, followed by
trastuzumab 6mg/kg IV every 3 weeks (Day 1 and Day 22 of all subsequent cycles); CYCLE LENGTH: 42 days; COURSE: 9 cycles
(one year of therapy = 18 doses) for adjuvant or until disease progression for advanced.
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 1:24:30 PM Page 2 of 21
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) 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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 12/19/2016 through 1/29/2017 (42 days), Planned
Day 1, Cycle 2 – Planned for 12/19/2016
Treatment Plan Information
Reference Information (1)
BREAST CANCER: Leyland-Jones B, et al. J Clin Oncol 2003;21:3965-71.
Treatment Plan Summary
DISEASE: Breast Cancer (Adjuvant/Advanced); THERAPY: trastuzumab 8mg/kg IV Loading Dose Cycle 1 Day 1, followed by
trastuzumab 6mg/kg IV every 3 weeks (Day 1 and Day 22 of all subsequent cycles); CYCLE LENGTH: 42 days; COURSE: 9 cycles
(one year of therapy = 18 doses) for adjuvant or until disease progression for advanced.
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.
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 1:24:30 PM Page 3 of 21
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) 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.
Follow-Up
DAY 22 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: trastuzumab for 30 minutes.
DAY 43 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; CHEMOTHERAPY ROOM APPOINTMENT: trastuzumab
for 30 minutes.
Day 22, Cycle 2 – Planned for 1/9/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Adjuvant/Advanced); THERAPY: trastuzumab 8mg/kg IV Loading Dose Cycle 1 Day 1, followed by
trastuzumab 6mg/kg IV every 3 weeks (Day 1 and Day 22 of all subsequent cycles); CYCLE LENGTH: 42 days; COURSE: 9 cycles
(one year of therapy = 18 doses) for adjuvant or until disease progression for advanced.
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.
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ZZtestonc,Andrew [2428787]
11/7/2016 1:24:30 PM Page 4 of 21
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.
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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 – 1/30/2017 through 3/12/2017 (42 days), Planned
Day 1, Cycle 3 – Planned for 1/30/2017
Treatment Plan Information
Reference Information (1)
BREAST CANCER: Leyland-Jones B, et al. J Clin Oncol 2003;21:3965-71.
Treatment Plan Summary
DISEASE: Breast Cancer (Adjuvant/Advanced); THERAPY: trastuzumab 8mg/kg IV Loading Dose Cycle 1 Day 1, followed by
trastuzumab 6mg/kg IV every 3 weeks (Day 1 and Day 22 of all subsequent cycles); CYCLE LENGTH: 42 days; COURSE: 9 cycles
(one year of therapy = 18 doses) for adjuvant or until disease progression for advanced.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
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ZZtestonc,Andrew [2428787]
11/7/2016 1:24:30 PM Page 5 of 21
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) 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.
Follow-Up
DAY 22 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: trastuzumab for 30 minutes.
DAY 43 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; CHEMOTHERAPY ROOM APPOINTMENT: trastuzumab
for 30 minutes.
Day 22, Cycle 3 – Planned for 2/20/2017
Treatment Plan Information
Treatment Plan Summary
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ZZtestonc,Andrew [2428787]
11/7/2016 1:24:30 PM Page 6 of 21
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DISEASE: Breast Cancer (Adjuvant/Advanced); THERAPY: trastuzumab 8mg/kg IV Loading Dose Cycle 1 Day 1, followed by
trastuzumab 6mg/kg IV every 3 weeks (Day 1 and Day 22 of all subsequent cycles); CYCLE LENGTH: 42 days; COURSE: 9 cycles
(one year of therapy = 18 doses) for adjuvant or until disease progression for advanced.
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) 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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 – 3/13/2017 through 4/23/2017 (42 days), Planned
Day 1, Cycle 4 – Planned for 3/13/2017
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ZZtestonc,Andrew [2428787]
11/7/2016 1:24:30 PM Page 7 of 21
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Plan Information
Reference Information (1)
BREAST CANCER: Leyland-Jones B, et al. J Clin Oncol 2003;21:3965-71.
Treatment Plan Summary
DISEASE: Breast Cancer (Adjuvant/Advanced); THERAPY: trastuzumab 8mg/kg IV Loading Dose Cycle 1 Day 1, followed by
trastuzumab 6mg/kg IV every 3 weeks (Day 1 and Day 22 of all subsequent cycles); CYCLE LENGTH: 42 days; COURSE: 9 cycles
(one year of therapy = 18 doses) for adjuvant or until disease progression for advanced.
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.
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) 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.
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ZZtestonc,Andrew [2428787]
11/7/2016 1:24:30 PM Page 8 of 21
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Follow-Up
DAY 22 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: trastuzumab for 30 minutes.
DAY 43 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; CHEMOTHERAPY ROOM APPOINTMENT: trastuzumab
for 30 minutes.
Day 22, Cycle 4 – Planned for 4/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Adjuvant/Advanced); THERAPY: trastuzumab 8mg/kg IV Loading Dose Cycle 1 Day 1, followed by
trastuzumab 6mg/kg IV every 3 weeks (Day 1 and Day 22 of all subsequent cycles); CYCLE LENGTH: 42 days; COURSE: 9 cycles
(one year of therapy = 18 doses) for adjuvant or until disease progression for advanced.
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) 476 mg in sodium chloride 0.9 % 250 mL bag
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ZZtestonc,Andrew [2428787]
11/7/2016 1:24:30 PM Page 9 of 21
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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 – 4/24/2017 through 6/4/2017 (42 days), Planned
Day 1, Cycle 5 – Planned for 4/24/2017
Treatment Plan Information
Reference Information (1)
BREAST CANCER: Leyland-Jones B, et al. J Clin Oncol 2003;21:3965-71.
Treatment Plan Summary
DISEASE: Breast Cancer (Adjuvant/Advanced); THERAPY: trastuzumab 8mg/kg IV Loading Dose Cycle 1 Day 1, followed by
trastuzumab 6mg/kg IV every 3 weeks (Day 1 and Day 22 of all subsequent cycles); CYCLE LENGTH: 42 days; COURSE: 9 cycles
(one year of therapy = 18 doses) for adjuvant or until disease progression for advanced.
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.
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
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ZZtestonc,Andrew [2428787]
11/7/2016 1:24:30 PM Page 10 of 21
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) 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.
Follow-Up
DAY 22 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: trastuzumab for 30 minutes.
DAY 43 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; CHEMOTHERAPY ROOM APPOINTMENT: trastuzumab
for 30 minutes.
Day 22, Cycle 5 – Planned for 5/15/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Adjuvant/Advanced); THERAPY: trastuzumab 8mg/kg IV Loading Dose Cycle 1 Day 1, followed by
trastuzumab 6mg/kg IV every 3 weeks (Day 1 and Day 22 of all subsequent cycles); CYCLE LENGTH: 42 days; COURSE: 9 cycles
(one year of therapy = 18 doses) for adjuvant or until disease progression for advanced.
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
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ZZtestonc,Andrew [2428787]
11/7/2016 1:24:30 PM Page 11 of 21
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, 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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 6 – 6/5/2017 through 7/16/2017 (42 days), Planned
Day 1, Cycle 6 – Planned for 6/5/2017
Treatment Plan Information
Reference Information (1)
BREAST CANCER: Leyland-Jones B, et al. J Clin Oncol 2003;21:3965-71.
Treatment Plan Summary
DISEASE: Breast Cancer (Adjuvant/Advanced); THERAPY: trastuzumab 8mg/kg IV Loading Dose Cycle 1 Day 1, followed by
trastuzumab 6mg/kg IV every 3 weeks (Day 1 and Day 22 of all subsequent cycles); CYCLE LENGTH: 42 days; COURSE: 9 cycles
(one year of therapy = 18 doses) for adjuvant or until disease progression for advanced.
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.
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 1:24:30 PM Page 12 of 21
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.
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.
Follow-Up
DAY 22 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: trastuzumab for 30 minutes.
DAY 43 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; CHEMOTHERAPY ROOM APPOINTMENT: trastuzumab
for 30 minutes.
Day 22, Cycle 6 – Planned for 6/26/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Adjuvant/Advanced); THERAPY: trastuzumab 8mg/kg IV Loading Dose Cycle 1 Day 1, followed by
trastuzumab 6mg/kg IV every 3 weeks (Day 1 and Day 22 of all subsequent cycles); CYCLE LENGTH: 42 days; COURSE: 9 cycles
(one year of therapy = 18 doses) for adjuvant or until disease progression for advanced.
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.
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ZZtestonc,Andrew [2428787]
11/7/2016 1:24:30 PM Page 13 of 21
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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) 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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 7 – 7/17/2017 through 8/27/2017 (42 days), Planned
Day 1, Cycle 7 – Planned for 7/17/2017
Treatment Plan Information
Reference Information (1)
BREAST CANCER: Leyland-Jones B, et al. J Clin Oncol 2003;21:3965-71.
Treatment Plan Summary
DISEASE: Breast Cancer (Adjuvant/Advanced); THERAPY: trastuzumab 8mg/kg IV Loading Dose Cycle 1 Day 1, followed by
trastuzumab 6mg/kg IV every 3 weeks (Day 1 and Day 22 of all subsequent cycles); CYCLE LENGTH: 42 days; COURSE: 9 cycles
(one year of therapy = 18 doses) for adjuvant or until disease progression for advanced.
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.
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 1:24:30 PM Page 14 of 21
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.
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.
Follow-Up
DAY 22 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: trastuzumab for 30 minutes.
DAY 43 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; CHEMOTHERAPY ROOM APPOINTMENT: trastuzumab
for 30 minutes.
Day 22, Cycle 7 – Planned for 8/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Adjuvant/Advanced); THERAPY: trastuzumab 8mg/kg IV Loading Dose Cycle 1 Day 1, followed by
trastuzumab 6mg/kg IV every 3 weeks (Day 1 and Day 22 of all subsequent cycles); CYCLE LENGTH: 42 days; COURSE: 9 cycles
(one year of therapy = 18 doses) for adjuvant or until disease progression for advanced.
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
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ZZtestonc,Andrew [2428787]
11/7/2016 1:24:30 PM Page 15 of 21
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Hypersensitivity Monitoring (1)
Hypersensitivity reaction to 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) 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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 8 – 8/28/2017 through 10/8/2017 (42 days), Planned
Day 1, Cycle 8 – Planned for 8/28/2017
Treatment Plan Information
Reference Information (1)
BREAST CANCER: Leyland-Jones B, et al. J Clin Oncol 2003;21:3965-71.
Treatment Plan Summary
DISEASE: Breast Cancer (Adjuvant/Advanced); THERAPY: trastuzumab 8mg/kg IV Loading Dose Cycle 1 Day 1, followed by
trastuzumab 6mg/kg IV every 3 weeks (Day 1 and Day 22 of all subsequent cycles); CYCLE LENGTH: 42 days; COURSE: 9 cycles
(one year of therapy = 18 doses) for adjuvant or until disease progression for advanced.
Consent
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ZZtestonc,Andrew [2428787]
11/7/2016 1:24:30 PM Page 16 of 21
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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.
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) 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.
Follow-Up
DAY 22 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: trastuzumab for 30 minutes.
DAY 43 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; CHEMOTHERAPY ROOM APPOINTMENT: trastuzumab
for 30 minutes.
Day 22, Cycle 8 – Planned for 9/18/2017
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ZZtestonc,Andrew [2428787]
11/7/2016 1:24:30 PM Page 17 of 21
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Adjuvant/Advanced); THERAPY: trastuzumab 8mg/kg IV Loading Dose Cycle 1 Day 1, followed by
trastuzumab 6mg/kg IV every 3 weeks (Day 1 and Day 22 of all subsequent cycles); CYCLE LENGTH: 42 days; COURSE: 9 cycles
(one year of therapy = 18 doses) for adjuvant or until disease progression for advanced.
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) 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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 9 – 10/9/2017 through 10/30/2017 (22 days), Planned
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ZZtestonc,Andrew [2428787]
11/7/2016 1:24:30 PM Page 18 of 21
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Day 1, Cycle 9 – Planned for 10/9/2017
Treatment Plan Information
Reference Information (1)
BREAST CANCER: Leyland-Jones B, et al. J Clin Oncol 2003;21:3965-71.
Treatment Plan Summary
DISEASE: Breast Cancer (Adjuvant/Advanced); THERAPY: trastuzumab 8mg/kg IV Loading Dose Cycle 1 Day 1, followed by
trastuzumab 6mg/kg IV every 3 weeks (Day 1 and Day 22 of all subsequent cycles); CYCLE LENGTH: 42 days; COURSE: 9 cycles
(one year of therapy = 18 doses) for adjuvant or until disease progression for advanced.
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.
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
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ZZtestonc,Andrew [2428787]
11/7/2016 1:24:30 PM Page 19 of 21
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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.
Follow-Up
DAY 22 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: trastuzumab for 30 minutes.
DAY 50 FOLLOW-UP
RETURN TO CLINIC in one month after last trastuzumab dose for appointment with provider.
Day 22, Cycle 9 – Planned for 10/30/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Adjuvant/Advanced); THERAPY: trastuzumab 8mg/kg IV Loading Dose Cycle 1 Day 1, followed by
trastuzumab 6mg/kg IV every 3 weeks (Day 1 and Day 22 of all subsequent cycles); CYCLE LENGTH: 42 days; COURSE: 9 cycles
(one year of therapy = 18 doses) for adjuvant or until disease progression for advanced.
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
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ZZtestonc,Andrew [2428787]
11/7/2016 1:24:30 PM Page 20 of 21
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
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.
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 1:24:30 PM Page 21 of 21
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org