/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-96620-en.cckm

201611312

page

100

UWHC,UWMF,

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

CSC Breast Vinorelbine (21D1,8) VER 10-3-16 (HL 567)

CSC Breast Vinorelbine (21D1,8) VER 10-3-16 (HL 567) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Breast


CSC BREAST 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: vinorelbine 25 to 30 mg/m2 IV Day 1 and 8; CYCLE LENGTH: 21 days; COURSE: 6
cycles.
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;17:630-6.
Treatment Plan Summary
DISEASE: Breast (Advanced); THERAPY: vinorelbine 25 to 30 mg/m2 IV Day 1 and 8; CYCLE LENGTH: 21 days; COURSE: 6
cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
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ZZtestonc,Andrew [2428787]
11/7/2016 1:25:55 PM Page 1 of 15
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
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
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: vinorelbine for 45 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 for 45
minutes.
Day 8, Cycle 1 – Planned for 11/14/2016
Treatment Plan Information
Reference Information (1)
BREAST CANCER: Papaldo, P, et al. Ann Oncol 2006;17:630-6.
Treatment Plan Summary
DISEASE: Breast (Advanced); THERAPY: vinorelbine 25 to 30 mg/m2 IV Day 1 and 8; CYCLE LENGTH: 21 days; COURSE: 6
cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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ZZtestonc,Andrew [2428787]
11/7/2016 1:25:55 PM Page 2 of 15
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL.
Nursing Procedure, Assessment and Monitoring
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 next day appointment(s) have been scheduled. See follow-up section on Day 1.
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;17:630-6.
Treatment Plan Summary
DISEASE: Breast (Advanced); THERAPY: vinorelbine 25 to 30 mg/m2 IV Day 1 and 8; CYCLE LENGTH: 21 days; COURSE: 6
cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
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ZZtestonc,Andrew [2428787]
11/7/2016 1:25:55 PM Page 3 of 15
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+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
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
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ZZtestonc,Andrew [2428787]
11/7/2016 1:25:55 PM Page 4 of 15
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 45
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 for 45 minutes.
Day 8, Cycle 2 – Planned for 12/5/2016
Treatment Plan Information
Reference Information (1)
BREAST CANCER: Papaldo, P, et al. Ann Oncol 2006;17:630-6.
Treatment Plan Summary
DISEASE: Breast (Advanced); THERAPY: vinorelbine 25 to 30 mg/m2 IV Day 1 and 8; CYCLE LENGTH: 21 days; COURSE: 6
cycles.
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
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ZZtestonc,Andrew [2428787]
11/7/2016 1:25:55 PM Page 5 of 15
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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 next day appointment(s) have been scheduled. See follow-up section on Day 1.
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;17:630-6.
Treatment Plan Summary
DISEASE: Breast (Advanced); THERAPY: vinorelbine 25 to 30 mg/m2 IV Day 1 and 8; CYCLE LENGTH: 21 days; COURSE: 6
cycles.
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
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 1:25:55 PM Page 6 of 15
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
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: vinorelbine for 45 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 for 45 minutes.
Day 8, Cycle 3 – Planned for 12/26/2016
Treatment Plan Information
Reference Information (1)
BREAST CANCER: Papaldo, P, et al. Ann Oncol 2006;17:630-6.
Treatment Plan Summary
DISEASE: Breast (Advanced); THERAPY: vinorelbine 25 to 30 mg/m2 IV Day 1 and 8; CYCLE LENGTH: 21 days; COURSE: 6
cycles.
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
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ZZtestonc,Andrew [2428787]
11/7/2016 1:25:55 PM Page 7 of 15
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
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 next day appointment(s) have been scheduled. See follow-up section on Day 1.
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;17:630-6.
Treatment Plan Summary
DISEASE: Breast (Advanced); THERAPY: vinorelbine 25 to 30 mg/m2 IV Day 1 and 8; CYCLE LENGTH: 21 days; COURSE: 6
cycles.
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
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ZZtestonc,Andrew [2428787]
11/7/2016 1:25:55 PM Page 8 of 15
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
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
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: vinorelbine for 45 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 for 45 minutes.
Day 8, Cycle 4 – Planned for 1/16/2017
Treatment Plan Information
Reference Information (1)
BREAST CANCER: Papaldo, P, et al. Ann Oncol 2006;17:630-6.
Treatment Plan Summary
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ZZtestonc,Andrew [2428787]
11/7/2016 1:25:55 PM Page 9 of 15
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DISEASE: Breast (Advanced); THERAPY: vinorelbine 25 to 30 mg/m2 IV Day 1 and 8; CYCLE LENGTH: 21 days; COURSE: 6
cycles.
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 next day appointment(s) have been scheduled. See follow-up section on Day 1.
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)
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ZZtestonc,Andrew [2428787]
11/7/2016 1:25:55 PM Page 10 of 15
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

BREAST CANCER: Papaldo, P, et al. Ann Oncol 2006;17:630-6.
Treatment Plan Summary
DISEASE: Breast (Advanced); THERAPY: vinorelbine 25 to 30 mg/m2 IV Day 1 and 8; CYCLE LENGTH: 21 days; COURSE: 6
cycles.
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
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 1:25:55 PM Page 11 of 15
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
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: vinorelbine for 45 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 for 45 minutes.
Day 8, Cycle 5 – Planned for 2/6/2017
Treatment Plan Information
Reference Information (1)
BREAST CANCER: Papaldo, P, et al. Ann Oncol 2006;17:630-6.
Treatment Plan Summary
DISEASE: Breast (Advanced); THERAPY: vinorelbine 25 to 30 mg/m2 IV Day 1 and 8; CYCLE LENGTH: 21 days; COURSE: 6
cycles.
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
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ZZtestonc,Andrew [2428787]
11/7/2016 1:25:55 PM Page 12 of 15
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.
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 next day appointment(s) have been scheduled. See follow-up section on Day 1.
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;17:630-6.
Treatment Plan Summary
DISEASE: Breast (Advanced); THERAPY: vinorelbine 25 to 30 mg/m2 IV Day 1 and 8; CYCLE LENGTH: 21 days; COURSE: 6
cycles.
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
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ZZtestonc,Andrew [2428787]
11/7/2016 1:25:55 PM Page 13 of 15
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Verify pretreatment labs have been obtained: CBC, ANC, Total Bilirubin, 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
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
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: vinorelbine for 45 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 for 45 minutes.
Day 8, Cycle 6 – Planned for 2/27/2017
Treatment Plan Information
Reference Information (1)
BREAST CANCER: Papaldo, P, et al. Ann Oncol 2006;17:630-6.
Treatment Plan Summary
DISEASE: Breast (Advanced); THERAPY: vinorelbine 25 to 30 mg/m2 IV Day 1 and 8; CYCLE LENGTH: 21 days; COURSE: 6
cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
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ZZtestonc,Andrew [2428787]
11/7/2016 1:25:55 PM Page 14 of 15
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 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 next day appointment(s) have been scheduled. See follow-up section on Day 1.
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ZZtestonc,Andrew [2428787]
11/7/2016 1:25:55 PM Page 15 of 15
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org