/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-98656-en.cckm

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 Fulvestrant Palbociclib (28D1-21) VER 10-3-16 (HL 6101)

CSC Breast Fulvestrant Palbociclib (28D1-21) VER 10-3-16 (HL 6101) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Breast


CSC BREAST FULVESTRANT/PALBOCICLIB (28D:1-21) 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: palbociclib 125 mg by mouth once daily Days 1 through 21, fulvestrant 500 mg IM
Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 1 cycle, followed by THERAPY: palbociclib 125 mg by mouth once daily Days
1 through 21, fulvestrant 500 mg IM Day 1; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
ALT/SGPT
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
BILIRUBIN, TOTAL
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 – 11/1/2016 through 11/28/2016 (28 days), Planned
Day 1, Cycle 1 – Planned for 11/1/2016
Treatment Plan Information
Reference Information (1)
BREAST CANCER: Finn RS, et al. Lancet Oncol 2015;16(1):25-35.
Reference Information (2)
BREAST CANCER: Turner NC, et al. N Engl J Med 2015;373(3):209-19.
Reference Information (3)
BREAST CANCER: IBRANCE (palbociclib) [package insert]. New York, NY; Pfizer; Revised February, 2015.
Reference Information (4)
BREAST CANCER: Cristofanilli M, et al. Lancet Oncol 2016;s1470-2045;doi:10.1016/S1470-2045(15)00613-0. [Epub ahead of
print].
Reference Information (5)
BREAST CANCER: NCCN Breast Cancer. Version 1.2016. Updated November 18, 2015. Accessed April 18, 2016.
http://www.nccn.org/professionals/physician_gls/pdf/breast.pdf.
Treatment Plan Summary
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ZZtestonc,Andrew [2428787]
11/1/2016 4:12:31 PM Page 1 of 10
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DISEASE: Breast Cancer (Advanced); THERAPY: palbociclib 125 mg by mouth once daily Days 1 through 21, fulvestrant 500 mg IM
Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 1 cycle, followed by THERAPY: palbociclib 125 mg by mouth once daily Days
1 through 21, fulvestrant 500 mg IM Day 1; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, AST, Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than 2 mg/dL or Total Bilirubin greater than 1.5 X ULN or AST greater than 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.
Treatment Medications
fulvestrant (FASLODEX) injection NF 250 mg
250 mg, Intramuscular, EVERY 5 MINUTES, 2 doses Starting when released
Total dose = 500 mg (2 syringes).
See Take Home Medication(s)
Refer to the Take Home Medications category for the following treatment medication(s): palbociclib dispensed Day 1 of each cycle.
Take Home Medications
palbociclib (IBRANCE) 125 MG cap
Take 1 cap by mouth one time daily. Days 1 through 21 of a 28 Day cycle. Swallow whole with food., 125 mg, Disp-21 cap, R-0,
1 X DAILY starting S
Follow-Up
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally). CHEMOTHERAPY ROOM APPOINTMENT: fulvestrant for 30 min.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Creatinine, ALT, AST, Alkaline
Phosphatase, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: fulvestrant for 30 min.
Day 15, Cycle 1 – Planned for 11/15/2016
Treatment Plan Information
Treatment Plan Summary
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ZZtestonc,Andrew [2428787]
11/1/2016 4:12:31 PM Page 2 of 10
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DISEASE: Breast Cancer (Advanced); THERAPY: palbociclib 125 mg by mouth once daily Days 1 through 21, fulvestrant 500 mg IM
Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 1 cycle, followed by THERAPY: palbociclib 125 mg by mouth once daily Days
1 through 21, fulvestrant 500 mg IM Day 1; CYCLE LENGTH: 28 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC without DIFF, ANC.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/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.
Treatment Medications
fulvestrant (FASLODEX) injection NF 250 mg
250 mg, Intramuscular, EVERY 5 MINUTES, 2 doses Starting when released
Total dose = 500 mg (2 syringes).
See Take Home Medication(s)
Refer to the Take Home Medications category for the following treatment medication(s): palbociclib dispensed Day 1 of each cycle.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 11/29/2016 through 12/26/2016 (28 days), Planned
Day 1, Cycle 2 – Planned for 11/29/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: palbociclib 125 mg by mouth once daily Days 1 through 21, fulvestrant 500 mg IM
Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 1 cycle, followed by THERAPY: palbociclib 125 mg by mouth once daily Days
1 through 21, fulvestrant 500 mg IM Day 1; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Consent
Verify Consent
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ZZtestonc,Andrew [2428787]
11/1/2016 4:12:31 PM Page 3 of 10
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
ALT/SGPT
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
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, AST, Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than 2 mg/dL or Total Bilirubin greater than 1.5 X ULN or AST greater than 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.
Treatment Medications
fulvestrant (FASLODEX) injection NF 250 mg
250 mg, Intramuscular, EVERY 5 MINUTES, 2 doses Starting when released
Total dose = 500 mg (2 syringes).
See Take Home Medication(s)
Refer to the Take Home Medications category for the following treatment medication(s): palbociclib dispensed Day 1 of each cycle.
Take Home Medications
palbociclib (IBRANCE) 125 MG cap
Take 1 cap by mouth one time daily. Days 1 through 21 of a 28 Day cycle. Swallow whole with food., 125 mg, Disp-21 cap, R-0,
1 X DAILY starting S
Follow-Up
DAY 29 FOLLOW-UP
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ZZtestonc,Andrew [2428787]
11/1/2016 4:12:31 PM Page 4 of 10
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

(Day 1 of next cycle) LABS: CBC with DIFF, Creatinine, ALT, AST, Alkaline Phosphatase, Total Bilirubin. CHEMOTHERAPY ROOM
APPOINTMENT: fulvestrant for 30 min.
Cycle 3 – 12/27/2016 through 1/23/2017 (28 days), Planned
Day 1, Cycle 3 – Planned for 12/27/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: palbociclib 125 mg by mouth once daily Days 1 through 21, fulvestrant 500 mg IM
Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 1 cycle, followed by THERAPY: palbociclib 125 mg by mouth once daily Days
1 through 21, fulvestrant 500 mg IM Day 1; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, AST, Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than 2 mg/dL or Total Bilirubin greater than 1.5 X ULN or AST greater than 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.
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ZZtestonc,Andrew [2428787]
11/1/2016 4:12:31 PM Page 5 of 10
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Medications
fulvestrant (FASLODEX) injection NF 250 mg
250 mg, Intramuscular, EVERY 5 MINUTES, 2 doses Starting when released
Total dose = 500 mg (2 syringes).
See Take Home Medication(s)
Refer to the Take Home Medications category for the following treatment medication(s): palbociclib dispensed Day 1 of each cycle.
Take Home Medications
palbociclib (IBRANCE) 125 MG cap
Take 1 cap by mouth one time daily. Days 1 through 21 of a 28 Day cycle. Swallow whole with food., 125 mg, Disp-21 cap, R-0,
1 X DAILY starting S
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Creatinine, ALT, AST, Alkaline
Phosphatase,Total Bilirubin. CHEMOTHERAPY ROOM APPOINTMENT: fulvestrant for 30 minutes.
Cycle 4 – 1/24/2017 through 2/20/2017 (28 days), Planned
Day 1, Cycle 4 – Planned for 1/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: palbociclib 125 mg by mouth once daily Days 1 through 21, fulvestrant 500 mg IM
Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 1 cycle, followed by THERAPY: palbociclib 125 mg by mouth once daily Days
1 through 21, fulvestrant 500 mg IM Day 1; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, AST, Total Bilirubin.
Treatment Parameters
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ZZtestonc,Andrew [2428787]
11/1/2016 4:12:31 PM Page 6 of 10
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than 2 mg/dL or Total Bilirubin greater than 1.5 X ULN or AST greater than 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.
Treatment Medications
fulvestrant (FASLODEX) injection NF 250 mg
250 mg, Intramuscular, EVERY 5 MINUTES, 2 doses Starting when released
Total dose = 500 mg (2 syringes).
See Take Home Medication(s)
Refer to the Take Home Medications category for the following treatment medication(s): palbociclib dispensed Day 1 of each cycle.
Take Home Medications
palbociclib (IBRANCE) 125 MG cap
Take 1 cap by mouth one time daily. Days 1 through 21 of a 28 Day cycle. Swallow whole with food., 125 mg, Disp-21 cap, R-0,
1 X DAILY starting S
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Creatinine, ALT, AST, Alkaline
Phosphatase,Total Bilirubin. CHEMOTHERAPY ROOM APPOINTMENT: fulvestrant for 30 minutes.
Cycle 5 – 2/21/2017 through 3/20/2017 (28 days), Planned
Day 1, Cycle 5 – Planned for 2/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: palbociclib 125 mg by mouth once daily Days 1 through 21, fulvestrant 500 mg IM
Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 1 cycle, followed by THERAPY: palbociclib 125 mg by mouth once daily Days
1 through 21, fulvestrant 500 mg IM Day 1; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
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ZZtestonc,Andrew [2428787]
11/1/2016 4:12:31 PM Page 7 of 10
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

ALT/SGPT
Expected-S+28 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, AST, Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than 2 mg/dL or Total Bilirubin greater than 1.5 X ULN or AST greater than 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.
Treatment Medications
fulvestrant (FASLODEX) injection NF 250 mg
250 mg, Intramuscular, EVERY 5 MINUTES, 2 doses Starting when released
Total dose = 500 mg (2 syringes).
See Take Home Medication(s)
Refer to the Take Home Medications category for the following treatment medication(s): palbociclib dispensed Day 1 of each cycle.
Take Home Medications
palbociclib (IBRANCE) 125 MG cap
Take 1 cap by mouth one time daily. Days 1 through 21 of a 28 Day cycle. Swallow whole with food., 125 mg, Disp-21 cap, R-0,
1 X DAILY starting S
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Creatinine, ALT, AST, Alkaline
Phosphatase,Total Bilirubin. CHEMOTHERAPY ROOM APPOINTMENT: fulvestrant for 30 minutes.
Cycle 6 – 3/21/2017 through 4/17/2017 (28 days), Planned
Day 1, Cycle 6 – Planned for 3/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: palbociclib 125 mg by mouth once daily Days 1 through 21, fulvestrant 500 mg IM
Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 1 cycle, followed by THERAPY: palbociclib 125 mg by mouth once daily Days
1 through 21, fulvestrant 500 mg IM Day 1; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Consent
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ZZtestonc,Andrew [2428787]
11/1/2016 4:12:31 PM Page 8 of 10
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+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, AST, Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than 2 mg/dL or Total Bilirubin greater than 1.5 X ULN or AST greater than 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.
Treatment Medications
fulvestrant (FASLODEX) injection NF 250 mg
250 mg, Intramuscular, EVERY 5 MINUTES, 2 doses Starting when released
Total dose = 500 mg (2 syringes).
See Take Home Medication(s)
Refer to the Take Home Medications category for the following treatment medication(s): palbociclib dispensed Day 1 of each cycle.
Take Home Medications
palbociclib (IBRANCE) 125 MG cap
Take 1 cap by mouth one time daily. Days 1 through 21 of a 28 Day cycle. Swallow whole with food., 125 mg, Disp-21 cap, R-0,
1 X DAILY starting S
Follow-Up
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ZZtestonc,Andrew [2428787]
11/1/2016 4:12:31 PM Page 9 of 10
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Creatinine, ALT, AST, Alkaline
Phosphatase,Total Bilirubin. CHEMOTHERAPY ROOM APPOINTMENT: fulvestrant for 30 minutes.
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