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201611306

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100

UWHC,UWMF,

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

CSC Breast Everolimus(28D 1-28) VER 10-3-16 (HL 4808)

CSC Breast Everolimus(28D 1-28) VER 10-3-16 (HL 4808) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Breast


CSC BREAST EVEROLIMUS(28D:1-28) VER: 10-3-16 – Properties
Pre-Cycle – 10/25/2016 through 10/31/2016 (7 days), Planned
Day 1, Pre-Cycle – Planned for 10/25/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: everolimus 10 mg by mouth daily continuously; CYCLE LENGTH: 28 days;
COURSE: 1 cycle followed by THERAPY: everolimus 10 mg by mouth daily continuously; CYCLE LENGTH: 56 days; COURSE:
until disease progression. NOTE: must be used with exemestane.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S Approximate, Expires-S+365, Routine
BUN
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
CALCIUM
Expected-S Approximate, Expires-S+365, Routine
Lipid Panel
Expected-S Approximate, Expires-S+365, Routine
Patient should be fasting minimum 12 hours. The patient can only have water, black coffee or calorie free drinks during the fasting
period.
Cycle 1 – 11/1/2016 through 11/28/2016 (28 days), Planned
Day 1, Cycle 1 – Planned for 11/1/2016
Treatment Plan Information
Reference Information (1)
BREAST CANCER: Baselga J, et al. N Eng J Med. 2012;366(6):520-9.
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: everolimus 10 mg by mouth daily continuously; CYCLE LENGTH: 28 days;
COURSE: 1 cycle followed by THERAPY: everolimus 10 mg by mouth daily continuously; CYCLE LENGTH: 56 days; COURSE:
until disease progression. NOTE: must be used with exemestane.
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.
Treatment Conditions
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ZZtestonc,Andrew [2428787]
11/1/2016 4:10:53 PM Page 1 of 8
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 75K/µL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Stomatitis is a common side effect of everolimus. Educate patient on the importance of good oral hygiene. If mouth sores become
severe, contact the clinic.
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.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): everolimus and exemestane (dispensed Day 1
of Cycle 1 only- subsequent refills will be ordered through the medication activity).
Take Home Medications
everolimus (AFINITOR) 10 MG tab
Take 1 tab by mouth one time daily., 10 mg, Disp-28 tab, R-0, 1 X DAILY starting S, Local Printer
exemestane (AROMASIN) 25 MG tab
Take 1 tab by mouth one time daily., 25 mg, Disp-30 tab, R-0, 1 X DAILY starting S, Local Printer
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS:CBC with DIFF, Electrolytes, Glucose, BUN,
Creatinine, Calcium.
Cycle 2 – 11/29/2016 through 1/23/2017 (56 days), Planned
Day 1, Cycle 2 – Planned for 11/29/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: everolimus 10 mg by mouth daily continuously; CYCLE LENGTH: 28 days;
COURSE: 1 cycle followed by THERAPY: everolimus 10 mg by mouth daily continuously; CYCLE LENGTH: 56 days; COURSE:
until disease progression. NOTE: must be used with exemestane.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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ZZtestonc,Andrew [2428787]
11/1/2016 4:10:53 PM Page 2 of 8
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

CBC WITH DIFFERENTIAL
Expected-S+56 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+56 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+56 Approximate, Expires-S+365, Routine
BUN
Expected-S+56 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+56 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+56 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 75K/µL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Stomatitis is a common side effect of everolimus. Educate patient on the importance of good oral hygiene. If mouth sores become
severe, contact the clinic.
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.
Treatment Medications
Oral Chemotherapy Order Management
For this regimen, exemestane and everolimus will be ordered through the medication activity after the initial order.
Follow-Up
DAY 57 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS:CBC with DIFF, Electrolytes, Glucose, BUN,
Creatinine, Calcium.
Cycle 3 – 1/24/2017 through 3/20/2017 (56 days), Planned
Day 1, Cycle 3 – Planned for 1/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: everolimus 10 mg by mouth daily continuously; CYCLE LENGTH: 28 days;
COURSE: 1 cycle followed by THERAPY: everolimus 10 mg by mouth daily continuously; CYCLE LENGTH: 56 days; COURSE:
until disease progression. NOTE: must be used with exemestane.
Consent
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ZZtestonc,Andrew [2428787]
11/1/2016 4:10:53 PM Page 3 of 8
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.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+56 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+56 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+56 Approximate, Expires-S+365, Routine
BUN
Expected-S+56 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+56 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+56 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 75K/µL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Stomatitis is a common side effect of everolimus. Educate patient on the importance of good oral hygiene. If mouth sores become
severe, contact the clinic.
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.
Treatment Medications
Oral Chemotherapy Order Management
For this regimen, exemestane and everolimus will be ordered through the medication activity after the initial order.
Follow-Up
DAY 57 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS:CBC with DIFF, Electrolytes, Glucose, BUN,
Creatinine, Calcium.
Cycle 4 – 3/21/2017 through 5/15/2017 (56 days), Planned
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ZZtestonc,Andrew [2428787]
11/1/2016 4:10:53 PM Page 4 of 8
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Day 1, Cycle 4 – Planned for 3/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: everolimus 10 mg by mouth daily continuously; CYCLE LENGTH: 28 days;
COURSE: 1 cycle followed by THERAPY: everolimus 10 mg by mouth daily continuously; CYCLE LENGTH: 56 days; COURSE:
until disease progression. NOTE: must be used with exemestane.
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 WITH DIFFERENTIAL
Expected-S+56 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+56 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+56 Approximate, Expires-S+365, Routine
BUN
Expected-S+56 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+56 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+56 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 75K/µL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Stomatitis is a common side effect of everolimus. Educate patient on the importance of good oral hygiene. If mouth sores become
severe, contact the clinic.
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.
Treatment Medications
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ZZtestonc,Andrew [2428787]
11/1/2016 4:10:53 PM Page 5 of 8
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Oral Chemotherapy Order Management
For this regimen, exemestane and everolimus will be ordered through the medication activity after the initial order.
Follow-Up
DAY 57 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS:CBC with DIFF, Electrolytes, Glucose, BUN,
Creatinine, Calcium.
Cycle 5 – 5/16/2017 through 7/10/2017 (56 days), Planned
Day 1, Cycle 5 – Planned for 5/16/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: everolimus 10 mg by mouth daily continuously; CYCLE LENGTH: 28 days;
COURSE: 1 cycle followed by THERAPY: everolimus 10 mg by mouth daily continuously; CYCLE LENGTH: 56 days; COURSE:
until disease progression. NOTE: must be used with exemestane.
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 WITH DIFFERENTIAL
Expected-S+56 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+56 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+56 Approximate, Expires-S+365, Routine
BUN
Expected-S+56 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+56 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+56 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 75K/µL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Stomatitis is a common side effect of everolimus. Educate patient on the importance of good oral hygiene. If mouth sores become
severe, contact the clinic.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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ZZtestonc,Andrew [2428787]
11/1/2016 4:10:53 PM Page 6 of 8
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.
Treatment Medications
Oral Chemotherapy Order Management
For this regimen, exemestane and everolimus will be ordered through the medication activity after the initial order.
Follow-Up
DAY 57 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS:CBC with DIFF, Electrolytes, Glucose, BUN,
Creatinine, Calcium.
Cycle 6 – 7/11/2017 through 9/4/2017 (56 days), Planned
Day 1, Cycle 6 – Planned for 7/11/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: everolimus 10 mg by mouth daily continuously; CYCLE LENGTH: 28 days;
COURSE: 1 cycle followed by THERAPY: everolimus 10 mg by mouth daily continuously; CYCLE LENGTH: 56 days; COURSE:
until disease progression. NOTE: must be used with exemestane.
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 WITH DIFFERENTIAL
Expected-S+56 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+56 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+56 Approximate, Expires-S+365, Routine
BUN
Expected-S+56 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+56 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+56 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
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ZZtestonc,Andrew [2428787]
11/1/2016 4:10:53 PM Page 7 of 8
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 75K/µL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Stomatitis is a common side effect of everolimus. Educate patient on the importance of good oral hygiene. If mouth sores become
severe, contact the clinic.
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.
Treatment Medications
Oral Chemotherapy Order Management
For this regimen, exemestane and everolimus will be ordered through the medication activity after the initial order.
Follow-Up
DAY 57 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS:CBC with DIFF, Electrolytes, Glucose, BUN,
Creatinine, Calcium.
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ZZtestonc,Andrew [2428787]
11/1/2016 4:10:53 PM Page 8 of 8
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org