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201708223

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

CSC GI Fluorouracil(28D:1,15) Leucovorin(28D:1,15) Oxalplatin(28D:1,15) Trastuzumab(28D:1,15) VER 8-15-17 (HL5580)

CSC GI Fluorouracil(28D:1,15) Leucovorin(28D:1,15) Oxalplatin(28D:1,15) Trastuzumab(28D:1,15) VER 8-15-17 (HL5580) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GI


CSC GI  FLUOROURACIL(28D:1,15)/LEUCOVORIN(28D:1,15)/OXALIPLATIN(28D:1,15)/TRASTUZUMAB
(28D:1,15) VER: 8-15-17 –  Properties
Pre-Cycle –  8/3/2017 through 8/9/2017 (7 days), Planned
Day 1, Pre-Cycle –  Planned for 8/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Esophageal/Gastric Cancer (Advanced); THERAPY: trastuzumab 6 mg/kg IV Day 1, trastuzumab 4 mg/kg IV
Day 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus
Day 1 and 15, followed by fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours (Total dose
= 2400 mg/m2 IV over 46 hours per cycle per home infusion) on Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by THERAPY: trastuzumab 4 mg/kg IV Day 1 and 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin
200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by fluorouracil 2400 mg/m2
administered as a continuous infusion IV over 46 hours (Total dose = 2400 mg/m2 IV over 46 hours per cycle per home
infusion) on Day 1 and 15; CYCLE LENGTH: 28 days;  COURSE: until disease progression.
Note to All Staff (1)
Chemotherapy Council approved for HER2 amplified unresectable/metastatic esophageal/gastric cancer.
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
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
AST/SGOT
Expected: S Approximate, Expires: S+365, Routine
ALT/SGPT
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
Nursing Procedure, Assessment and Monitoring
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Zztestonc,Jeff J [2507481]
8/10/2017 8:55:50 AM Page 1 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Page Or Call ___________
Notify Home infusion provider.
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
dexamethasone (DECADRON) 4 MG tab
Take 2 tabs by mouth one time daily. Take for 3 days following chemotherapy, 8 mg, Disp-24 tab, R-5, 1 X DAILY
starting S, Local Printer
Cycle 1 –  8/10/2017 through 9/6/2017 (28 days), Planned
Day 1, Cycle 1 –  Planned for 8/10/2017
Treatment Plan Information
Reference Information (1)
GASTROESOPHAGEAL CANCER: Bang YJ, et al. Lancet 2010;376(9742):687-97.
Treatment Plan Summary
DISEASE: Esophageal/Gastric Cancer (Advanced); THERAPY: trastuzumab 6 mg/kg IV Day 1, trastuzumab 4 mg/kg IV
Day 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus
Day 1 and 15, followed by fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours (Total dose
= 2400 mg/m2 IV over 46 hours per cycle per home infusion) on Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by THERAPY: trastuzumab 4 mg/kg IV Day 1 and 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin
200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by fluorouracil 2400 mg/m2
administered as a continuous infusion IV over 46 hours (Total dose = 2400 mg/m2 IV over 46 hours per cycle per home
infusion) on Day 1 and 15; CYCLE LENGTH: 28 days;  COURSE: until disease progression.
Note to All Staff (1)
Chemotherapy Council approved for HER2 amplified unresectable/metastatic esophageal/gastric cancer.
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, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 75K/µL.
Treatment Condition A
Check for mucositis, irritation of hands or feet, or diarrhea.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
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Zztestonc,Jeff J [2507481]
8/10/2017 8:55:50 AM Page 2 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@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.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to oxaliplatin can occur.  For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine or continuous fluorouracil
infusion and to call with concerns.
Patient Instructions(2)
Educate/reinforce with patient regarding "cold neuropathy" that occurs with oxaliplatin.
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 lock flush 10 UNIT/ML 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.
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
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 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
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Zztestonc,Jeff J [2507481]
8/10/2017 8:55:50 AM Page 3 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Treatment Medications
trastuzumab (HERCEPTIN) 450 mg in sodium chloride 0.9 % 250 mL bag
450 mg (rounded from 486 mg = 6 mg/kg × 81 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 90 Minutes
Trastuzumab should be given PRIOR to any chemotherapy. Give first dose over 90 minutes and subsequent doses over
30 minutes. Hypersensitivity reaction to trastuzumab can occur. 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 first
dose of trastuzumab.
oxaliplatin (ELOXATIN) 166.5 mg in dextrose 5 % 250 mL bag
166.5 mg (rounded from 166.6 mg = 85 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Incompatible with Sodium Chloride. Allow adequate flushing with Dextrose 5% in Water when necessary between
chemotherapy treatment medications. Hypersensitivity reaction to oxaliplatin can occur. For first and second dose,
patient should be treated in a location to optimize emergency care. See Emergency Medications.
leucovorin 392 mg in dextrose 5 % 500 mL bag
392 mg (200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer (via separate infusion lines) concurrently with oxaliplatin.
fluorouracil (ADRUCIL) injection 784 mg
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released, Administer over 5-15 Minutes
IV bolus over 5 to 15 minutes.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
Follow-Up
DAY 3 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: trastuzumab, oxaliplatin,
fluorouracil, leucovorin for 180 minutes.
DAY 17 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Calcium, Total Bilirubin, AST, ALT, Alkaline Phosphatase; CHEMOTHERAPY ROOM
APPOINTMENT: trastuzumab, oxaliplatin, fluorouracil, leucovorin for 180 minutes.
Day 3 (Pump Disconnect), Cycle 1 –  Planned for 8/12/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Esophageal/Gastric Cancer (Advanced); THERAPY: trastuzumab 6 mg/kg IV Day 1, trastuzumab 4 mg/kg IV
Day 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus
Day 1 and 15, followed by fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours (Total dose
= 2400 mg/m2 IV over 46 hours per cycle per home infusion) on Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by THERAPY: trastuzumab 4 mg/kg IV Day 1 and 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin
200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by fluorouracil 2400 mg/m2
administered as a continuous infusion IV over 46 hours (Total dose = 2400 mg/m2 IV over 46 hours per cycle per home
infusion) on Day 1 and 15; CYCLE LENGTH: 28 days;  COURSE: until disease progression.
Note to All Staff (1)
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Zztestonc,Jeff J [2507481]
8/10/2017 8:55:50 AM Page 4 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Chemotherapy Council approved for HER2 amplified unresectable/metastatic esophageal/gastric cancer.
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 lock flush 10 UNIT/ML 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
Pump Disconnection Procedures
Disconnect pump upon completion of 46-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 1 –  Planned for 8/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Esophageal/Gastric Cancer (Advanced); THERAPY: trastuzumab 6 mg/kg IV Day 1, trastuzumab 4 mg/kg IV
Day 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus
Day 1 and 15, followed by fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours (Total dose
= 2400 mg/m2 IV over 46 hours per cycle per home infusion) on Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by THERAPY: trastuzumab 4 mg/kg IV Day 1 and 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin
200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by fluorouracil 2400 mg/m2
administered as a continuous infusion IV over 46 hours (Total dose = 2400 mg/m2 IV over 46 hours per cycle per home
infusion) on Day 1 and 15; CYCLE LENGTH: 28 days;  COURSE: until disease progression.
Note to All Staff (1)
Chemotherapy Council approved for HER2 amplified unresectable/metastatic esophageal/gastric cancer.
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
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Zztestonc,Jeff J [2507481]
8/10/2017 8:55:50 AM Page 5 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Verify pretreatment labs have been obtained:  CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 75K/µL.
Treatment Condition A
Check for mucositis, irritation of hands or feet, or diarrhea.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
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.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to oxaliplatin can occur.  For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine or continuous fluorouracil
infusion and to call with concerns.
Patient Instructions(2)
Educate/reinforce with patient regarding "cold neuropathy" that occurs with oxaliplatin.
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 lock flush 10 UNIT/ML 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.
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
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Zztestonc,Jeff J [2507481]
8/10/2017 8:55:50 AM Page 6 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
trastuzumab (HERCEPTIN) 300 mg in sodium chloride 0.9 % 250 mL bag
300 mg (rounded from 324 mg = 4 mg/kg × 81 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 30 Minutes
Administer over 30 minutes. Trastuzumab should be given PRIOR to any chemotherapy. 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.
oxaliplatin (ELOXATIN) 166.5 mg in dextrose 5 % 250 mL bag
166.5 mg (rounded from 166.6 mg = 85 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Incompatible with Sodium Chloride. Allow adequate flushing with Dextrose 5% in Water when necessary between
chemotherapy treatment medications. Hypersensitivity reaction to oxaliplatin can occur. For first and second dose,
patient should be treated in a location to optimize emergency care. See Emergency Medications.
leucovorin 392 mg in dextrose 5 % 500 mL bag
392 mg (200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer (via separate infusion lines) concurrently with oxaliplatin.
fluorouracil (ADRUCIL) injection 784 mg
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released, Administer over 5-15 Minutes
IV bolus over 5 to 15 minutes.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 17 (Pump Disconnect), Cycle 1 –  Planned for 8/26/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Esophageal/Gastric Cancer (Advanced); THERAPY: trastuzumab 6 mg/kg IV Day 1, trastuzumab 4 mg/kg IV
Day 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus
Day 1 and 15, followed by fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours (Total dose
= 2400 mg/m2 IV over 46 hours per cycle per home infusion) on Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by THERAPY: trastuzumab 4 mg/kg IV Day 1 and 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin
200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by fluorouracil 2400 mg/m2
administered as a continuous infusion IV over 46 hours (Total dose = 2400 mg/m2 IV over 46 hours per cycle per home
infusion) on Day 1 and 15; CYCLE LENGTH: 28 days;  COURSE: until disease progression.
Note to All Staff (1)
Chemotherapy Council approved for HER2 amplified unresectable/metastatic esophageal/gastric cancer.
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Zztestonc,Jeff J [2507481]
8/10/2017 8:55:50 AM Page 7 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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 lock flush 10 UNIT/ML 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
Pump Disconnection Procedures
Disconnect pump upon completion of 46-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 –  9/7/2017 through 10/4/2017 (28 days), Planned
Day 1, Cycle 2 –  Planned for 9/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Esophageal/Gastric Cancer (Advanced); THERAPY: trastuzumab 6 mg/kg IV Day 1, trastuzumab 4 mg/kg IV
Day 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus
Day 1 and 15, followed by fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours (Total dose
= 2400 mg/m2 IV over 46 hours per cycle per home infusion) on Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by THERAPY: trastuzumab 4 mg/kg IV Day 1 and 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin
200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by fluorouracil 2400 mg/m2
administered as a continuous infusion IV over 46 hours (Total dose = 2400 mg/m2 IV over 46 hours per cycle per home
infusion) on Day 1 and 15; CYCLE LENGTH: 28 days;  COURSE: until disease progression.
Note to All Staff (1)
Chemotherapy Council approved for HER2 amplified unresectable/metastatic esophageal/gastric cancer.
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
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Zztestonc,Jeff J [2507481]
8/10/2017 8:55:50 AM Page 8 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+14 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+14 Approximate, Expires: S+365, Routine
BUN
Expected: S+14 Approximate, Expires: S+365, Routine
CREATININE
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
ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Routine
CALCIUM
Expected: S+14 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 1,000/µL or Platelets less than 75K/µL.
Treatment Condition A
Check for mucositis, irritation of hands or feet, or diarrhea.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
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.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to oxaliplatin can occur.  For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine or continuous fluorouracil
infusion and to call with concerns.
Patient Instructions(2)
Educate/reinforce with patient regarding "cold neuropathy" that occurs with oxaliplatin.
Flush Venous Access Device per Guidelines
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Zztestonc,Jeff J [2507481]
8/10/2017 8:55:50 AM Page 9 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@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 lock flush 10 UNIT/ML 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.
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
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 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
trastuzumab (HERCEPTIN) 300 mg in sodium chloride 0.9 % 250 mL bag
300 mg (rounded from 324 mg = 4 mg/kg × 81 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 30 Minutes
Administer over 30 minutes. Trastuzumab should be given PRIOR to any chemotherapy. 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.
oxaliplatin (ELOXATIN) 166.5 mg in dextrose 5 % 250 mL bag
166.5 mg (rounded from 166.6 mg = 85 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Incompatible with Sodium Chloride. Allow adequate flushing with Dextrose 5% in Water when necessary between
chemotherapy treatment medications. Hypersensitivity reaction to oxaliplatin can occur. For first and second dose,
patient should be treated in a location to optimize emergency care. See Emergency Medications.
leucovorin 392 mg in dextrose 5 % 500 mL bag
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Zztestonc,Jeff J [2507481]
8/10/2017 8:55:50 AM Page 10 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

392 mg (200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer (via separate infusion lines) concurrently with oxaliplatin.
fluorouracil (ADRUCIL) injection 784 mg
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released, Administer over 5-15 Minutes
IV bolus over 5 to 15 minutes.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
Follow-Up
DAY 3 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: trastuzumab, oxaliplatin,
fluorouracil, leucovorin for 180 minutes.
DAY 17 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Calcium, Total Bilirubin, AST, ALT, Alkaline Phosphatase; CHEMOTHERAPY ROOM
APPOINTMENT: trastuzumab, oxaliplatin, fluorouracil, leucovorin for 180 minutes.
Day 3 (Pump Disconnect), Cycle 2 –  Planned for 9/9/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Esophageal/Gastric Cancer (Advanced); THERAPY: trastuzumab 6 mg/kg IV Day 1, trastuzumab 4 mg/kg IV
Day 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus
Day 1 and 15, followed by fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours (Total dose
= 2400 mg/m2 IV over 46 hours per cycle per home infusion) on Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by THERAPY: trastuzumab 4 mg/kg IV Day 1 and 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin
200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by fluorouracil 2400 mg/m2
administered as a continuous infusion IV over 46 hours (Total dose = 2400 mg/m2 IV over 46 hours per cycle per home
infusion) on Day 1 and 15; CYCLE LENGTH: 28 days;  COURSE: until disease progression.
Note to All Staff (1)
Chemotherapy Council approved for HER2 amplified unresectable/metastatic esophageal/gastric cancer.
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 lock flush 10 UNIT/ML 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,Jeff J [2507481]
8/10/2017 8:55:50 AM Page 11 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Treatment Medications
Pump Disconnection Procedures
Disconnect pump upon completion of 46-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 2 –  Planned for 9/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Esophageal/Gastric Cancer (Advanced); THERAPY: trastuzumab 6 mg/kg IV Day 1, trastuzumab 4 mg/kg IV
Day 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus
Day 1 and 15, followed by fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours (Total dose
= 2400 mg/m2 IV over 46 hours per cycle per home infusion) on Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by THERAPY: trastuzumab 4 mg/kg IV Day 1 and 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin
200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by fluorouracil 2400 mg/m2
administered as a continuous infusion IV over 46 hours (Total dose = 2400 mg/m2 IV over 46 hours per cycle per home
infusion) on Day 1 and 15; CYCLE LENGTH: 28 days;  COURSE: until disease progression.
Note to All Staff (1)
Chemotherapy Council approved for HER2 amplified unresectable/metastatic esophageal/gastric cancer.
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, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 75K/µL.
Treatment Condition A
Check for mucositis, irritation of hands or feet, or diarrhea.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
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,Jeff J [2507481]
8/10/2017 8:55:50 AM Page 12 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Hypersensitivity Monitoring (2)
Hypersensitivity reaction to oxaliplatin can occur.  For first and second dose, patient should be treated
in a location to optimize emergency care. See Emergency Medications.
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine or continuous fluorouracil
infusion and to call with concerns.
Patient Instructions(2)
Educate/reinforce with patient regarding "cold neuropathy" that occurs with oxaliplatin.
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 lock flush 10 UNIT/ML 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.
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
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 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
trastuzumab (HERCEPTIN) 300 mg in sodium chloride 0.9 % 250 mL bag
300 mg (rounded from 324 mg = 4 mg/kg × 81 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 30 Minutes
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Zztestonc,Jeff J [2507481]
8/10/2017 8:55:50 AM Page 13 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Administer over 30 minutes. Trastuzumab should be given PRIOR to any chemotherapy. 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.
oxaliplatin (ELOXATIN) 166.5 mg in dextrose 5 % 250 mL bag
166.5 mg (rounded from 166.6 mg = 85 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Incompatible with Sodium Chloride. Allow adequate flushing with Dextrose 5% in Water when necessary between
chemotherapy treatment medications. Hypersensitivity reaction to oxaliplatin can occur. For first and second dose,
patient should be treated in a location to optimize emergency care. See Emergency Medications.
leucovorin 392 mg in dextrose 5 % 500 mL bag
392 mg (200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer (via separate infusion lines) concurrently with oxaliplatin.
fluorouracil (ADRUCIL) injection 784 mg
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released, Administer over 5-15 Minutes
IV bolus over 5 to 15 minutes.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 17 (Pump Disconnect), Cycle 2 –  Planned for 9/23/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Esophageal/Gastric Cancer (Advanced); THERAPY: trastuzumab 6 mg/kg IV Day 1, trastuzumab 4 mg/kg IV
Day 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus
Day 1 and 15, followed by fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours (Total dose
= 2400 mg/m2 IV over 46 hours per cycle per home infusion) on Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by THERAPY: trastuzumab 4 mg/kg IV Day 1 and 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin
200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by fluorouracil 2400 mg/m2
administered as a continuous infusion IV over 46 hours (Total dose = 2400 mg/m2 IV over 46 hours per cycle per home
infusion) on Day 1 and 15; CYCLE LENGTH: 28 days;  COURSE: until disease progression.
Note to All Staff (1)
Chemotherapy Council approved for HER2 amplified unresectable/metastatic esophageal/gastric cancer.
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 lock flush 10 UNIT/ML 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,Jeff J [2507481]
8/10/2017 8:55:50 AM Page 14 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Treatment Medications
Pump Disconnection Procedures
Disconnect pump upon completion of 46-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 –  10/5/2017 through 11/1/2017 (28 days), Planned
Day 1, Cycle 3 –  Planned for 10/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Esophageal/Gastric Cancer (Advanced); THERAPY: trastuzumab 6 mg/kg IV Day 1, trastuzumab 4 mg/kg IV
Day 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus
Day 1 and 15, followed by fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours (Total dose
= 2400 mg/m2 IV over 46 hours per cycle per home infusion) on Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by THERAPY: trastuzumab 4 mg/kg IV Day 1 and 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin
200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by fluorouracil 2400 mg/m2
administered as a continuous infusion IV over 46 hours (Total dose = 2400 mg/m2 IV over 46 hours per cycle per home
infusion) on Day 1 and 15; CYCLE LENGTH: 28 days;  COURSE: until disease progression.
Note to All Staff (1)
Chemotherapy Council approved for HER2 amplified unresectable/metastatic esophageal/gastric cancer.
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
ELECTROLYTES
Expected: S+14 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+14 Approximate, Expires: S+365, Routine
BUN
Expected: S+14 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+14 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
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Zztestonc,Jeff J [2507481]
8/10/2017 8:55:50 AM Page 15 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Expected: S+14 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+14 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Routine
CALCIUM
Expected: S+14 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 1,000/µL or Platelets less than 75K/µL.
Treatment Condition A
Check for mucositis, irritation of hands or feet, or diarrhea.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
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.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to oxaliplatin can occur.  For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine or continuous fluorouracil
infusion and to call with concerns.
Patient Instructions(2)
Educate/reinforce with patient regarding "cold neuropathy" that occurs with oxaliplatin.
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 lock flush 10 UNIT/ML 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
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Zztestonc,Jeff J [2507481]
8/10/2017 8:55:50 AM Page 16 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
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 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
trastuzumab (HERCEPTIN) 300 mg in sodium chloride 0.9 % 250 mL bag
300 mg (rounded from 324 mg = 4 mg/kg × 81 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 30 Minutes
Administer over 30 minutes. Trastuzumab should be given PRIOR to any chemotherapy. 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.
oxaliplatin (ELOXATIN) 166.5 mg in dextrose 5 % 250 mL bag
166.5 mg (rounded from 166.6 mg = 85 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Incompatible with Sodium Chloride. Allow adequate flushing with Dextrose 5% in Water when necessary between
chemotherapy treatment medications. Hypersensitivity reaction to oxaliplatin can occur. For first and second dose,
patient should be treated in a location to optimize emergency care. See Emergency Medications.
leucovorin 392 mg in dextrose 5 % 500 mL bag
392 mg (200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer (via separate infusion lines) concurrently with oxaliplatin.
fluorouracil (ADRUCIL) injection 784 mg
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released, Administer over 5-15 Minutes
IV bolus over 5 to 15 minutes.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
Follow-Up
DAY 3 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
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Zztestonc,Jeff J [2507481]
8/10/2017 8:55:50 AM Page 17 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: trastuzumab, oxaliplatin,
fluorouracil, leucovorin for 180 minutes.
DAY 17 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Calcium, Total Bilirubin, AST, ALT, Alkaline Phosphatase; CHEMOTHERAPY ROOM
APPOINTMENT: trastuzumab, oxaliplatin, fluorouracil, leucovorin for 180 minutes.
Day 3 (Pump Disconnect), Cycle 3 –  Planned for 10/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Esophageal/Gastric Cancer (Advanced); THERAPY: trastuzumab 6 mg/kg IV Day 1, trastuzumab 4 mg/kg IV
Day 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus
Day 1 and 15, followed by fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours (Total dose
= 2400 mg/m2 IV over 46 hours per cycle per home infusion) on Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by THERAPY: trastuzumab 4 mg/kg IV Day 1 and 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin
200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by fluorouracil 2400 mg/m2
administered as a continuous infusion IV over 46 hours (Total dose = 2400 mg/m2 IV over 46 hours per cycle per home
infusion) on Day 1 and 15; CYCLE LENGTH: 28 days;  COURSE: until disease progression.
Note to All Staff (1)
Chemotherapy Council approved for HER2 amplified unresectable/metastatic esophageal/gastric cancer.
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 lock flush 10 UNIT/ML 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
Pump Disconnection Procedures
Disconnect pump upon completion of 46-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 3 –  Planned for 10/19/2017
Treatment Plan Information
Treatment Plan Summary
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Zztestonc,Jeff J [2507481]
8/10/2017 8:55:50 AM Page 18 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

DISEASE: Esophageal/Gastric Cancer (Advanced); THERAPY: trastuzumab 6 mg/kg IV Day 1, trastuzumab 4 mg/kg IV
Day 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus
Day 1 and 15, followed by fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours (Total dose
= 2400 mg/m2 IV over 46 hours per cycle per home infusion) on Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by THERAPY: trastuzumab 4 mg/kg IV Day 1 and 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin
200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by fluorouracil 2400 mg/m2
administered as a continuous infusion IV over 46 hours (Total dose = 2400 mg/m2 IV over 46 hours per cycle per home
infusion) on Day 1 and 15; CYCLE LENGTH: 28 days;  COURSE: until disease progression.
Note to All Staff (1)
Chemotherapy Council approved for HER2 amplified unresectable/metastatic esophageal/gastric cancer.
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, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 75K/µL.
Treatment Condition A
Check for mucositis, irritation of hands or feet, or diarrhea.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
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.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to oxaliplatin can occur.  For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine or continuous fluorouracil
infusion and to call with concerns.
Patient Instructions(2)
Educate/reinforce with patient regarding "cold neuropathy" that occurs with oxaliplatin.
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.
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Zztestonc,Jeff J [2507481]
8/10/2017 8:55:50 AM Page 19 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

heparin lock flush 10 UNIT/ML 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.
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
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 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
trastuzumab (HERCEPTIN) 300 mg in sodium chloride 0.9 % 250 mL bag
300 mg (rounded from 324 mg = 4 mg/kg × 81 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 30 Minutes
Administer over 30 minutes. Trastuzumab should be given PRIOR to any chemotherapy. 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.
oxaliplatin (ELOXATIN) 166.5 mg in dextrose 5 % 250 mL bag
166.5 mg (rounded from 166.6 mg = 85 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Incompatible with Sodium Chloride. Allow adequate flushing with Dextrose 5% in Water when necessary between
chemotherapy treatment medications. Hypersensitivity reaction to oxaliplatin can occur. For first and second dose,
patient should be treated in a location to optimize emergency care. See Emergency Medications.
leucovorin 392 mg in dextrose 5 % 500 mL bag
392 mg (200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer (via separate infusion lines) concurrently with oxaliplatin.
fluorouracil (ADRUCIL) injection 784 mg
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Zztestonc,Jeff J [2507481]
8/10/2017 8:55:50 AM Page 20 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released, Administer over 5-15 Minutes
IV bolus over 5 to 15 minutes.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 17 (Pump Disconnect), Cycle 3 –  Planned for 10/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Esophageal/Gastric Cancer (Advanced); THERAPY: trastuzumab 6 mg/kg IV Day 1, trastuzumab 4 mg/kg IV
Day 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus
Day 1 and 15, followed by fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours (Total dose
= 2400 mg/m2 IV over 46 hours per cycle per home infusion) on Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by THERAPY: trastuzumab 4 mg/kg IV Day 1 and 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin
200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by fluorouracil 2400 mg/m2
administered as a continuous infusion IV over 46 hours (Total dose = 2400 mg/m2 IV over 46 hours per cycle per home
infusion) on Day 1 and 15; CYCLE LENGTH: 28 days;  COURSE: until disease progression.
Note to All Staff (1)
Chemotherapy Council approved for HER2 amplified unresectable/metastatic esophageal/gastric cancer.
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 lock flush 10 UNIT/ML 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
Pump Disconnection Procedures
Disconnect pump upon completion of 46-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 –  11/2/2017 through 11/29/2017 (28 days), Planned
Day 1, Cycle 4 –  Planned for 11/2/2017
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Zztestonc,Jeff J [2507481]
8/10/2017 8:55:50 AM Page 21 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Esophageal/Gastric Cancer (Advanced); THERAPY: trastuzumab 6 mg/kg IV Day 1, trastuzumab 4 mg/kg IV
Day 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus
Day 1 and 15, followed by fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours (Total dose
= 2400 mg/m2 IV over 46 hours per cycle per home infusion) on Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by THERAPY: trastuzumab 4 mg/kg IV Day 1 and 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin
200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by fluorouracil 2400 mg/m2
administered as a continuous infusion IV over 46 hours (Total dose = 2400 mg/m2 IV over 46 hours per cycle per home
infusion) on Day 1 and 15; CYCLE LENGTH: 28 days;  COURSE: until disease progression.
Note to All Staff (1)
Chemotherapy Council approved for HER2 amplified unresectable/metastatic esophageal/gastric cancer.
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
ELECTROLYTES
Expected: S+14 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+14 Approximate, Expires: S+365, Routine
BUN
Expected: S+14 Approximate, Expires: S+365, Routine
CREATININE
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
ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Routine
CALCIUM
Expected: S+14 Approximate, Expires: S+365, Routine
Treatment Conditions
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Zztestonc,Jeff J [2507481]
8/10/2017 8:55:50 AM Page 22 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Verify Labs
Verify pretreatment labs have been obtained:  CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 75K/µL.
Treatment Condition A
Check for mucositis, irritation of hands or feet, or diarrhea.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
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.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to oxaliplatin can occur.  For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine or continuous fluorouracil
infusion and to call with concerns.
Patient Instructions(2)
Educate/reinforce with patient regarding "cold neuropathy" that occurs with oxaliplatin.
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 lock flush 10 UNIT/ML 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.
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
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Zztestonc,Jeff J [2507481]
8/10/2017 8:55:50 AM Page 23 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@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 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
trastuzumab (HERCEPTIN) 300 mg in sodium chloride 0.9 % 250 mL bag
300 mg (rounded from 324 mg = 4 mg/kg × 81 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 30 Minutes
Administer over 30 minutes. Trastuzumab should be given PRIOR to any chemotherapy. 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.
oxaliplatin (ELOXATIN) 166.5 mg in dextrose 5 % 250 mL bag
166.5 mg (rounded from 166.6 mg = 85 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Incompatible with Sodium Chloride. Allow adequate flushing with Dextrose 5% in Water when necessary between
chemotherapy treatment medications. Hypersensitivity reaction to oxaliplatin can occur. For first and second dose,
patient should be treated in a location to optimize emergency care. See Emergency Medications.
leucovorin 392 mg in dextrose 5 % 500 mL bag
392 mg (200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer (via separate infusion lines) concurrently with oxaliplatin.
fluorouracil (ADRUCIL) injection 784 mg
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released, Administer over 5-15 Minutes
IV bolus over 5 to 15 minutes.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
Follow-Up
DAY 3 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: trastuzumab, oxaliplatin,
fluorouracil, leucovorin for 180 minutes.
DAY 17 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Calcium, Total Bilirubin, AST, ALT, Alkaline Phosphatase; CHEMOTHERAPY ROOM
APPOINTMENT: trastuzumab, oxaliplatin, fluorouracil, leucovorin for 180 minutes.
Day 3 (Pump Disconnect), Cycle 4 –  Planned for 11/4/2017
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Zztestonc,Jeff J [2507481]
8/10/2017 8:55:50 AM Page 24 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Esophageal/Gastric Cancer (Advanced); THERAPY: trastuzumab 6 mg/kg IV Day 1, trastuzumab 4 mg/kg IV
Day 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus
Day 1 and 15, followed by fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours (Total dose
= 2400 mg/m2 IV over 46 hours per cycle per home infusion) on Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by THERAPY: trastuzumab 4 mg/kg IV Day 1 and 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin
200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by fluorouracil 2400 mg/m2
administered as a continuous infusion IV over 46 hours (Total dose = 2400 mg/m2 IV over 46 hours per cycle per home
infusion) on Day 1 and 15; CYCLE LENGTH: 28 days;  COURSE: until disease progression.
Note to All Staff (1)
Chemotherapy Council approved for HER2 amplified unresectable/metastatic esophageal/gastric cancer.
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 lock flush 10 UNIT/ML 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
Pump Disconnection Procedures
Disconnect pump upon completion of 46-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 4 –  Planned for 11/16/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Esophageal/Gastric Cancer (Advanced); THERAPY: trastuzumab 6 mg/kg IV Day 1, trastuzumab 4 mg/kg IV
Day 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus
Day 1 and 15, followed by fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours (Total dose
= 2400 mg/m2 IV over 46 hours per cycle per home infusion) on Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by THERAPY: trastuzumab 4 mg/kg IV Day 1 and 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin
200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by fluorouracil 2400 mg/m2
administered as a continuous infusion IV over 46 hours (Total dose = 2400 mg/m2 IV over 46 hours per cycle per home
infusion) on Day 1 and 15; CYCLE LENGTH: 28 days;  COURSE: until disease progression.
Note to All Staff (1)
Chemotherapy Council approved for HER2 amplified unresectable/metastatic esophageal/gastric cancer.
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Jeff J [2507481]
8/10/2017 8:55:50 AM Page 25 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained:  CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 75K/µL.
Treatment Condition A
Check for mucositis, irritation of hands or feet, or diarrhea.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
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.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to oxaliplatin can occur.  For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine or continuous fluorouracil
infusion and to call with concerns.
Patient Instructions(2)
Educate/reinforce with patient regarding "cold neuropathy" that occurs with oxaliplatin.
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 lock flush 10 UNIT/ML 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,Jeff J [2507481]
8/10/2017 8:55:50 AM Page 26 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
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 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
trastuzumab (HERCEPTIN) 300 mg in sodium chloride 0.9 % 250 mL bag
300 mg (rounded from 324 mg = 4 mg/kg × 81 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 30 Minutes
Administer over 30 minutes. Trastuzumab should be given PRIOR to any chemotherapy. 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.
oxaliplatin (ELOXATIN) 166.5 mg in dextrose 5 % 250 mL bag
166.5 mg (rounded from 166.6 mg = 85 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Incompatible with Sodium Chloride. Allow adequate flushing with Dextrose 5% in Water when necessary between
chemotherapy treatment medications. Hypersensitivity reaction to oxaliplatin can occur. For first and second dose,
patient should be treated in a location to optimize emergency care. See Emergency Medications.
leucovorin 392 mg in dextrose 5 % 500 mL bag
392 mg (200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer (via separate infusion lines) concurrently with oxaliplatin.
fluorouracil (ADRUCIL) injection 784 mg
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released, Administer over 5-15 Minutes
IV bolus over 5 to 15 minutes.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 17 (Pump Disconnect), Cycle 4 –  Planned for 11/18/2017
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Zztestonc,Jeff J [2507481]
8/10/2017 8:55:50 AM Page 27 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Esophageal/Gastric Cancer (Advanced); THERAPY: trastuzumab 6 mg/kg IV Day 1, trastuzumab 4 mg/kg IV
Day 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus
Day 1 and 15, followed by fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours (Total dose
= 2400 mg/m2 IV over 46 hours per cycle per home infusion) on Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by THERAPY: trastuzumab 4 mg/kg IV Day 1 and 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin
200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by fluorouracil 2400 mg/m2
administered as a continuous infusion IV over 46 hours (Total dose = 2400 mg/m2 IV over 46 hours per cycle per home
infusion) on Day 1 and 15; CYCLE LENGTH: 28 days;  COURSE: until disease progression.
Note to All Staff (1)
Chemotherapy Council approved for HER2 amplified unresectable/metastatic esophageal/gastric cancer.
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 lock flush 10 UNIT/ML 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
Pump Disconnection Procedures
Disconnect pump upon completion of 46-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 –  11/30/2017 through 12/27/2017 (28 days), Planned
Day 1, Cycle 5 –  Planned for 11/30/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Esophageal/Gastric Cancer (Advanced); THERAPY: trastuzumab 6 mg/kg IV Day 1, trastuzumab 4 mg/kg IV
Day 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus
Day 1 and 15, followed by fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours (Total dose
= 2400 mg/m2 IV over 46 hours per cycle per home infusion) on Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by THERAPY: trastuzumab 4 mg/kg IV Day 1 and 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin
200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by fluorouracil 2400 mg/m2
administered as a continuous infusion IV over 46 hours (Total dose = 2400 mg/m2 IV over 46 hours per cycle per home
infusion) on Day 1 and 15; CYCLE LENGTH: 28 days;  COURSE: until disease progression.
Note to All Staff (1)
Chemotherapy Council approved for HER2 amplified unresectable/metastatic esophageal/gastric cancer.
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Zztestonc,Jeff J [2507481]
8/10/2017 8:55:50 AM Page 28 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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
ELECTROLYTES
Expected: S+14 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+14 Approximate, Expires: S+365, Routine
BUN
Expected: S+14 Approximate, Expires: S+365, Routine
CREATININE
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
ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Routine
CALCIUM
Expected: S+14 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 1,000/µL or Platelets less than 75K/µL.
Treatment Condition A
Check for mucositis, irritation of hands or feet, or diarrhea.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
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Zztestonc,Jeff J [2507481]
8/10/2017 8:55:50 AM Page 29 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@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.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to oxaliplatin can occur.  For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine or continuous fluorouracil
infusion and to call with concerns.
Patient Instructions(2)
Educate/reinforce with patient regarding "cold neuropathy" that occurs with oxaliplatin.
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 lock flush 10 UNIT/ML 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.
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
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 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
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Zztestonc,Jeff J [2507481]
8/10/2017 8:55:50 AM Page 30 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Treatment Medications
trastuzumab (HERCEPTIN) 300 mg in sodium chloride 0.9 % 250 mL bag
300 mg (rounded from 324 mg = 4 mg/kg × 81 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 30 Minutes
Administer over 30 minutes. Trastuzumab should be given PRIOR to any chemotherapy. 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.
oxaliplatin (ELOXATIN) 166.5 mg in dextrose 5 % 250 mL bag
166.5 mg (rounded from 166.6 mg = 85 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Incompatible with Sodium Chloride. Allow adequate flushing with Dextrose 5% in Water when necessary between
chemotherapy treatment medications. Hypersensitivity reaction to oxaliplatin can occur. For first and second dose,
patient should be treated in a location to optimize emergency care. See Emergency Medications.
leucovorin 392 mg in dextrose 5 % 500 mL bag
392 mg (200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer (via separate infusion lines) concurrently with oxaliplatin.
fluorouracil (ADRUCIL) injection 784 mg
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released, Administer over 5-15 Minutes
IV bolus over 5 to 15 minutes.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
Follow-Up
DAY 3 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: trastuzumab, oxaliplatin,
fluorouracil, leucovorin for 180 minutes.
DAY 17 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Calcium, Total Bilirubin, AST, ALT, Alkaline Phosphatase; CHEMOTHERAPY ROOM
APPOINTMENT: trastuzumab, oxaliplatin, fluorouracil, leucovorin for 180 minutes.
Day 3 (Pump Disconnect), Cycle 5 –  Planned for 12/2/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Esophageal/Gastric Cancer (Advanced); THERAPY: trastuzumab 6 mg/kg IV Day 1, trastuzumab 4 mg/kg IV
Day 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus
Day 1 and 15, followed by fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours (Total dose
= 2400 mg/m2 IV over 46 hours per cycle per home infusion) on Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by THERAPY: trastuzumab 4 mg/kg IV Day 1 and 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin
200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by fluorouracil 2400 mg/m2
administered as a continuous infusion IV over 46 hours (Total dose = 2400 mg/m2 IV over 46 hours per cycle per home
infusion) on Day 1 and 15; CYCLE LENGTH: 28 days;  COURSE: until disease progression.
Note to All Staff (1)
Chemotherapy Council approved for HER2 amplified unresectable/metastatic esophageal/gastric cancer.
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Zztestonc,Jeff J [2507481]
8/10/2017 8:55:50 AM Page 31 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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 lock flush 10 UNIT/ML 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
Pump Disconnection Procedures
Disconnect pump upon completion of 46-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 5 –  Planned for 12/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Esophageal/Gastric Cancer (Advanced); THERAPY: trastuzumab 6 mg/kg IV Day 1, trastuzumab 4 mg/kg IV
Day 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus
Day 1 and 15, followed by fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours (Total dose
= 2400 mg/m2 IV over 46 hours per cycle per home infusion) on Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by THERAPY: trastuzumab 4 mg/kg IV Day 1 and 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin
200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by fluorouracil 2400 mg/m2
administered as a continuous infusion IV over 46 hours (Total dose = 2400 mg/m2 IV over 46 hours per cycle per home
infusion) on Day 1 and 15; CYCLE LENGTH: 28 days;  COURSE: until disease progression.
Note to All Staff (1)
Chemotherapy Council approved for HER2 amplified unresectable/metastatic esophageal/gastric cancer.
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, ANC.
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Zztestonc,Jeff J [2507481]
8/10/2017 8:55:50 AM Page 32 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 75K/µL.
Treatment Condition A
Check for mucositis, irritation of hands or feet, or diarrhea.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
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.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to oxaliplatin can occur.  For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine or continuous fluorouracil
infusion and to call with concerns.
Patient Instructions(2)
Educate/reinforce with patient regarding "cold neuropathy" that occurs with oxaliplatin.
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 lock flush 10 UNIT/ML 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.
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
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Zztestonc,Jeff J [2507481]
8/10/2017 8:55:50 AM Page 33 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
trastuzumab (HERCEPTIN) 300 mg in sodium chloride 0.9 % 250 mL bag
300 mg (rounded from 324 mg = 4 mg/kg × 81 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 30 Minutes
Administer over 30 minutes. Trastuzumab should be given PRIOR to any chemotherapy. 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.
oxaliplatin (ELOXATIN) 166.5 mg in dextrose 5 % 250 mL bag
166.5 mg (rounded from 166.6 mg = 85 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Incompatible with Sodium Chloride. Allow adequate flushing with Dextrose 5% in Water when necessary between
chemotherapy treatment medications. Hypersensitivity reaction to oxaliplatin can occur. For first and second dose,
patient should be treated in a location to optimize emergency care. See Emergency Medications.
leucovorin 392 mg in dextrose 5 % 500 mL bag
392 mg (200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer (via separate infusion lines) concurrently with oxaliplatin.
fluorouracil (ADRUCIL) injection 784 mg
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released, Administer over 5-15 Minutes
IV bolus over 5 to 15 minutes.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 17 (Pump Disconnect), Cycle 5 –  Planned for 12/16/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Esophageal/Gastric Cancer (Advanced); THERAPY: trastuzumab 6 mg/kg IV Day 1, trastuzumab 4 mg/kg IV
Day 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus
Day 1 and 15, followed by fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours (Total dose
= 2400 mg/m2 IV over 46 hours per cycle per home infusion) on Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by THERAPY: trastuzumab 4 mg/kg IV Day 1 and 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin
200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by fluorouracil 2400 mg/m2
administered as a continuous infusion IV over 46 hours (Total dose = 2400 mg/m2 IV over 46 hours per cycle per home
infusion) on Day 1 and 15; CYCLE LENGTH: 28 days;  COURSE: until disease progression.
Note to All Staff (1)
Chemotherapy Council approved for HER2 amplified unresectable/metastatic esophageal/gastric cancer.
Nursing Procedure, Assessment and Monitoring
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Zztestonc,Jeff J [2507481]
8/10/2017 8:55:50 AM Page 34 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@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 lock flush 10 UNIT/ML 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
Pump Disconnection Procedures
Disconnect pump upon completion of 46-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 6 –  12/28/2017 through 1/24/2018 (28 days), Planned
Day 1, Cycle 6 –  Planned for 12/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Esophageal/Gastric Cancer (Advanced); THERAPY: trastuzumab 6 mg/kg IV Day 1, trastuzumab 4 mg/kg IV
Day 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus
Day 1 and 15, followed by fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours (Total dose
= 2400 mg/m2 IV over 46 hours per cycle per home infusion) on Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by THERAPY: trastuzumab 4 mg/kg IV Day 1 and 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin
200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by fluorouracil 2400 mg/m2
administered as a continuous infusion IV over 46 hours (Total dose = 2400 mg/m2 IV over 46 hours per cycle per home
infusion) on Day 1 and 15; CYCLE LENGTH: 28 days;  COURSE: until disease progression.
Note to All Staff (1)
Chemotherapy Council approved for HER2 amplified unresectable/metastatic esophageal/gastric cancer.
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
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Zztestonc,Jeff J [2507481]
8/10/2017 8:55:50 AM Page 35 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Expected: S+14 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+14 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+14 Approximate, Expires: S+365, Routine
BUN
Expected: S+14 Approximate, Expires: S+365, Routine
CREATININE
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
ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Routine
CALCIUM
Expected: S+14 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 1,000/µL or Platelets less than 75K/µL.
Treatment Condition A
Check for mucositis, irritation of hands or feet, or diarrhea.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
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.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to oxaliplatin can occur.  For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine or continuous fluorouracil
infusion and to call with concerns.
Patient Instructions(2)
Educate/reinforce with patient regarding "cold neuropathy" that occurs with oxaliplatin.
Flush Venous Access Device per Guidelines
Order details
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Zztestonc,Jeff J [2507481]
8/10/2017 8:55:50 AM Page 36 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML 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.
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
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 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
trastuzumab (HERCEPTIN) 300 mg in sodium chloride 0.9 % 250 mL bag
300 mg (rounded from 324 mg = 4 mg/kg × 81 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 30 Minutes
Administer over 30 minutes. Trastuzumab should be given PRIOR to any chemotherapy. 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.
oxaliplatin (ELOXATIN) 166.5 mg in dextrose 5 % 250 mL bag
166.5 mg (rounded from 166.6 mg = 85 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Incompatible with Sodium Chloride. Allow adequate flushing with Dextrose 5% in Water when necessary between
chemotherapy treatment medications. Hypersensitivity reaction to oxaliplatin can occur. For first and second dose,
patient should be treated in a location to optimize emergency care. See Emergency Medications.
leucovorin 392 mg in dextrose 5 % 500 mL bag
392 mg (200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer (via separate infusion lines) concurrently with oxaliplatin.
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Zztestonc,Jeff J [2507481]
8/10/2017 8:55:50 AM Page 37 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

fluorouracil (ADRUCIL) injection 784 mg
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released, Administer over 5-15 Minutes
IV bolus over 5 to 15 minutes.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
Follow-Up
DAY 3 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: trastuzumab, oxaliplatin,
fluorouracil, leucovorin for 180 minutes.
DAY 17 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Calcium, Total Bilirubin, AST, ALT, Alkaline Phosphatase; CHEMOTHERAPY ROOM
APPOINTMENT: trastuzumab, oxaliplatin, fluorouracil, leucovorin for 180 minutes.
Day 3 (Pump Disconnect), Cycle 6 –  Planned for 12/30/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Esophageal/Gastric Cancer (Advanced); THERAPY: trastuzumab 6 mg/kg IV Day 1, trastuzumab 4 mg/kg IV
Day 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus
Day 1 and 15, followed by fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours (Total dose
= 2400 mg/m2 IV over 46 hours per cycle per home infusion) on Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by THERAPY: trastuzumab 4 mg/kg IV Day 1 and 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin
200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by fluorouracil 2400 mg/m2
administered as a continuous infusion IV over 46 hours (Total dose = 2400 mg/m2 IV over 46 hours per cycle per home
infusion) on Day 1 and 15; CYCLE LENGTH: 28 days;  COURSE: until disease progression.
Note to All Staff (1)
Chemotherapy Council approved for HER2 amplified unresectable/metastatic esophageal/gastric cancer.
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 lock flush 10 UNIT/ML 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,Jeff J [2507481]
8/10/2017 8:55:50 AM Page 38 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Pump Disconnection Procedures
Disconnect pump upon completion of 46-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 6 –  Planned for 1/11/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Esophageal/Gastric Cancer (Advanced); THERAPY: trastuzumab 6 mg/kg IV Day 1, trastuzumab 4 mg/kg IV
Day 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus
Day 1 and 15, followed by fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours (Total dose
= 2400 mg/m2 IV over 46 hours per cycle per home infusion) on Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by THERAPY: trastuzumab 4 mg/kg IV Day 1 and 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin
200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by fluorouracil 2400 mg/m2
administered as a continuous infusion IV over 46 hours (Total dose = 2400 mg/m2 IV over 46 hours per cycle per home
infusion) on Day 1 and 15; CYCLE LENGTH: 28 days;  COURSE: until disease progression.
Note to All Staff (1)
Chemotherapy Council approved for HER2 amplified unresectable/metastatic esophageal/gastric cancer.
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, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 75K/µL.
Treatment Condition A
Check for mucositis, irritation of hands or feet, or diarrhea.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
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.
Hypersensitivity Monitoring (2)
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Zztestonc,Jeff J [2507481]
8/10/2017 8:55:50 AM Page 39 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Hypersensitivity reaction to oxaliplatin can occur.  For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine or continuous fluorouracil
infusion and to call with concerns.
Patient Instructions(2)
Educate/reinforce with patient regarding "cold neuropathy" that occurs with oxaliplatin.
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 lock flush 10 UNIT/ML 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.
dextrose 5 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
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 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
trastuzumab (HERCEPTIN) 300 mg in sodium chloride 0.9 % 250 mL bag
300 mg (rounded from 324 mg = 4 mg/kg × 81 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 30 Minutes
Administer over 30 minutes. Trastuzumab should be given PRIOR to any chemotherapy. Hypersensitivity reaction to
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Zztestonc,Jeff J [2507481]
8/10/2017 8:55:50 AM Page 40 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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.
oxaliplatin (ELOXATIN) 166.5 mg in dextrose 5 % 250 mL bag
166.5 mg (rounded from 166.6 mg = 85 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Incompatible with Sodium Chloride. Allow adequate flushing with Dextrose 5% in Water when necessary between
chemotherapy treatment medications. Hypersensitivity reaction to oxaliplatin can occur. For first and second dose,
patient should be treated in a location to optimize emergency care. See Emergency Medications.
leucovorin 392 mg in dextrose 5 % 500 mL bag
392 mg (200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer (via separate infusion lines) concurrently with oxaliplatin.
fluorouracil (ADRUCIL) injection 784 mg
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released, Administer over 5-15 Minutes
IV bolus over 5 to 15 minutes.
fluorouracil (ADRUCIL) home infusion bag 4,704 mg
4,704 mg (2,400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Fluorouracil Dose = 2400 mg/m2 administered as a single continuous infusion IV over 46 hours. (Total dose = 2400
mg/m2 IV over 46 hours per cycle per home infusion).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 17 (Pump Disconnect), Cycle 6 –  Planned for 1/13/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Esophageal/Gastric Cancer (Advanced); THERAPY: trastuzumab 6 mg/kg IV Day 1, trastuzumab 4 mg/kg IV
Day 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin 200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus
Day 1 and 15, followed by fluorouracil 2400 mg/m2 administered as a continuous infusion IV over 46 hours (Total dose
= 2400 mg/m2 IV over 46 hours per cycle per home infusion) on Day 1 and 15; CYCLE LENGTH: 28 days; COURSE: 1
cycle followed by THERAPY: trastuzumab 4 mg/kg IV Day 1 and 15, oxaliplatin 85 mg/m2 IV Day 1 and 15, leucovorin
200 mg/m2 IV Day 1 and 15, fluorouracil 400 mg/m2 IV bolus Day 1 and 15, followed by fluorouracil 2400 mg/m2
administered as a continuous infusion IV over 46 hours (Total dose = 2400 mg/m2 IV over 46 hours per cycle per home
infusion) on Day 1 and 15; CYCLE LENGTH: 28 days;  COURSE: until disease progression.
Note to All Staff (1)
Chemotherapy Council approved for HER2 amplified unresectable/metastatic esophageal/gastric cancer.
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 lock flush 10 UNIT/ML 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,Jeff J [2507481]
8/10/2017 8:55:50 AM Page 41 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Pump Disconnection Procedures
Disconnect pump upon completion of 46-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,Jeff J [2507481]
8/10/2017 8:55:50 AM Page 42 of 42
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org