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201708223

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CSC GI Capecitabine(21D:1-14) Cisplatin(21D:1) Trastuzumab(21D:1) VER 10-3-16 (HL 4399)

CSC GI Capecitabine(21D:1-14) Cisplatin(21D:1) Trastuzumab(21D:1) VER 10-3-16 (HL 4399) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GI


CSC GI CAPECITABINE(21D:1-14)/CISPLATIN(21D:1)/TRASTUZUMAB(21D:1) VER: 8-15-17 –  Properties
Pre-Cycle –  8/1/2017 through 8/7/2017 (7 days), Planned
Day 1, Pre-Cycle –  Planned for 8/1/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gastric/GE Junction Cancer (Advanced); THERAPY: Cycle 1: trastuzumab 8 mg/kg IV Day 1 (Loading Dose),
CISplatin 80 mg/m2 IV Day 1, capecitabine 1000 mg/m2 by mouth twice daily Day 1 through 14; Cycle 2 and all
subsequent cycles: trastuzumab 6 mg/kg IV Day 1; CISplatin 80 mg/m2 IV Day 1; capecitabine 1000 mg/m2 by mouth
twice daily Day 1 through 14; CYCLE LENGTH: 21 days; COURSE: until disease progression
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
MAGNESIUM
Expected: S Approximate, Expires: S+365, Routine
Take Home Medications
aprepitant (EMEND) 80 MG cap
Take 1 cap by mouth one time daily. Take for two days following chemotherapy., 80 mg, Disp-2 cap, R-5, 1 X DAILY
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
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed for nausea/vomiting., 8 mg, Disp-30 tab, R-5, EVERY 8 HOURS PRN
starting S, Local Printer
Cycle 1 –  8/8/2017 through 8/28/2017 (21 days), Planned
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Zztestonc,Jeff J [2507481]
8/8/2017 3:07:03 PM Page 1 of 18
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Day 1, Cycle 1 –  Planned for 8/8/2017
Treatment Plan Information
Reference Information (1)
GASTRIC/GE JUNCTION CANCER: Bang Y, et al. Lancet 2010;376:687-97
Treatment Plan Summary
DISEASE: Gastric/GE Junction Cancer (Advanced); THERAPY: Cycle 1: trastuzumab 8 mg/kg IV Day 1 (Loading Dose),
CISplatin 80 mg/m2 IV Day 1, capecitabine 1000 mg/m2 by mouth twice daily Day 1 through 14; Cycle 2 and all
subsequent cycles: trastuzumab 6 mg/kg IV Day 1; CISplatin 80 mg/m2 IV Day 1; capecitabine 1000 mg/m2 by mouth
twice daily Day 1 through 14; CYCLE LENGTH: 21 days; COURSE: until disease progression
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, and Magnesium.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 75K/µL or Creatinine greater
than 1.5 mg/dL or Magnesium less than 1.5 mg/dL.
Treatment Parameters (2)
Hold and notify authorizing prescriber for Ejection Fraction less than 50%.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to trastuzumab can occur.  For first and second dose, patient should be treated in a location to
optimize emergency care. Patient must be monitored for one hour after the first dose of trastuzumab. See Emergency
Medications.
Measure Intake And Output
SEE COMMENTS Starting when released Until Specified
Measure intake and output: If IV intake is greater than 2000 mL and urine output is less than 500 mL between start of
cisplatin and discharge, notify provider.
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)
RN instruct patient to drink 12 (8 ounce) glasses of water day of and for two days after treatment.
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
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Zztestonc,Jeff J [2507481]
8/8/2017 3:07:03 PM Page 2 of 18
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
sodium chloride 0.9 % infusion 500 mL
at 250-500 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
POST CISPLATIN HYDRATION. Delete if not needed.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 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) 600 mg in sodium chloride 0.9 % 250 mL bag
600 mg (rounded from 648 mg = 8 mg/kg × 81 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 90 Minutes
Hypersensitivity risk.  See emergency medications. Trastuzumab should be given prior to any chemotherapy. Administer
over 90 minutes. Patient must be monitored for one hour after the first dose of trastuzumab.
CISplatin (PLATINOL) 157 mg in sodium chloride 0.9 % 1,000 mL bag
157 mg (rounded from 156.8 mg = 80 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Administer over 60 to 90 minutes.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): capecitabine (Dispensed Day 1 of
each cycle).
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
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Zztestonc,Jeff J [2507481]
8/8/2017 3:07:03 PM Page 3 of 18
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Take Home Medications (delete all that do not apply)
capecitabine (XELODA) 500 MG tab
Take 4 tabs by mouth 2 times daily. Take on Day 1 through 14., 2,000 mg (rounded from 1,960 mg = 1,000 mg/m2 ×
1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
Round doses to available tablet sizes of 500mg and 150mg
capecitabine (XELODA) 150 MG tab
Take 13 tabs by mouth 2 times daily. Take on Day 1 through 14., 1,950 mg (rounded from 1,960 mg = 1,000 mg/m2
× 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
Round doses to available tablet sizes of 500mg and 150mg.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Calcium, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: CISplatin and
trastuzumab for 120 minutes.
Cycle 2 –  8/29/2017 through 9/18/2017 (21 days), Planned
Day 1, Cycle 2 –  Planned for 8/29/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gastric/GE Junction Cancer (Advanced); THERAPY: Cycle 1: trastuzumab 8 mg/kg IV Day 1 (Loading Dose),
CISplatin 80 mg/m2 IV Day 1, capecitabine 1000 mg/m2 by mouth twice daily Day 1 through 14; Cycle 2 and all
subsequent cycles: trastuzumab 6 mg/kg IV Day 1; CISplatin 80 mg/m2 IV Day 1; capecitabine 1000 mg/m2 by mouth
twice daily Day 1 through 14; CYCLE LENGTH: 21 days; COURSE: until disease progression
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+21 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+21 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+21 Approximate, Expires: S+365, Routine
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
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Zztestonc,Jeff J [2507481]
8/8/2017 3:07:03 PM Page 4 of 18
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

GLUCOSE
Expected: S+21 Approximate, Expires: S+365, Routine
BUN
Expected: S+21 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+21 Approximate, Expires: S+365, Routine
CALCIUM
Expected: S+21 Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S+21 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, and Magnesium.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 75K/µL or Creatinine greater
than 1.5 mg/dL or Magnesium less than 1.5 mg/dL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to trastuzumab can occur.  For first and second dose, patient should be treated in a location to
optimize emergency care. Patient must be monitored for one hour after the first dose of trastuzumab. See Emergency
Medications.
Measure Intake And Output
SEE COMMENTS Starting when released Until Specified
Measure intake and output: If IV intake is greater than 2000 mL and urine output is less than 500 mL between start of
cisplatin and discharge, notify provider.
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)
RN instruct patient to drink 12 (8 ounce) glasses of water day of and for two days after treatment.
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 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
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Zztestonc,Jeff J [2507481]
8/8/2017 3:07:03 PM Page 5 of 18
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

sodium chloride 0.9 % infusion 500 mL
at 250-500 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
POST CISPLATIN HYDRATION. Delete if not needed.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 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) 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
Hypersensitivity risk.  See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy.
Administer over 30 minutes. Patient must be monitored for one hour after the first dose of trastuzumab.
CISplatin (PLATINOL) 157 mg in sodium chloride 0.9 % 1,000 mL bag
157 mg (rounded from 156.8 mg = 80 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Administer over 60 to 90 minutes.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): capecitabine (Dispensed Day 1 of
each cycle).
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Take Home Medications (delete all that do not apply)
capecitabine (XELODA) 500 MG tab
Take 4 tabs by mouth 2 times daily. Take on Day 1 through 14., 2,000 mg (rounded from 1,960 mg = 1,000 mg/m2 ×
1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
Round doses to available tablet sizes of 500mg and 150mg
capecitabine (XELODA) 150 MG tab
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
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Zztestonc,Jeff J [2507481]
8/8/2017 3:07:03 PM Page 6 of 18
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Take 13 tabs by mouth 2 times daily. Take on Day 1 through 14., 1,950 mg (rounded from 1,960 mg
= 1,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
Round doses to available tablet sizes of 500mg and 150mg.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Calcium, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: CISplatin and
trastuzumab for 120 minutes.
Cycle 3 –  9/19/2017 through 10/9/2017 (21 days), Planned
Day 1, Cycle 3 –  Planned for 9/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gastric/GE Junction Cancer (Advanced); THERAPY: Cycle 1: trastuzumab 8 mg/kg IV Day 1 (Loading Dose),
CISplatin 80 mg/m2 IV Day 1, capecitabine 1000 mg/m2 by mouth twice daily Day 1 through 14; Cycle 2 and all
subsequent cycles: trastuzumab 6 mg/kg IV Day 1; CISplatin 80 mg/m2 IV Day 1; capecitabine 1000 mg/m2 by mouth
twice daily Day 1 through 14; CYCLE LENGTH: 21 days; COURSE: until disease progression
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+21 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+21 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+21 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+21 Approximate, Expires: S+365, Routine
BUN
Expected: S+21 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+21 Approximate, Expires: S+365, Routine
CALCIUM
Expected: S+21 Approximate, Expires: S+365, Routine
MAGNESIUM
This medication will not be e-prescribed. If patient is present, script will go to printer.
Otherwise, script will go to nursing or tech pool.   Invalid items: Pharmacy   
Details...
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Zztestonc,Jeff J [2507481]
8/8/2017 3:07:03 PM Page 7 of 18
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Expected: S+21 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, and Magnesium.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 75K/µL or Creatinine greater
than 1.5 mg/dL or Magnesium less than 1.5 mg/dL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to trastuzumab can occur.  For first and second dose, patient should be treated in a location to
optimize emergency care. Patient must be monitored for one hour after the first dose of trastuzumab. See Emergency
Medications.
Measure Intake And Output
SEE COMMENTS Starting when released Until Specified
Measure intake and output: If IV intake is greater than 2000 mL and urine output is less than 500 mL between start of
cisplatin and discharge, notify provider.
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)
RN instruct patient to drink 12 (8 ounce) glasses of water day of and for two days after treatment.
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 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
sodium chloride 0.9 % infusion 500 mL
at 250-500 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
POST CISPLATIN HYDRATION. Delete if not needed.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
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Zztestonc,Jeff J [2507481]
8/8/2017 3:07:03 PM Page 8 of 18
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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) 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
Hypersensitivity risk.  See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy.
Administer over 30 minutes. Patient must be monitored for one hour after the first dose of trastuzumab.
CISplatin (PLATINOL) 157 mg in sodium chloride 0.9 % 1,000 mL bag
157 mg (rounded from 156.8 mg = 80 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Administer over 60 to 90 minutes.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): capecitabine (Dispensed Day 1 of
each cycle).
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Take Home Medications (delete all that do not apply)
capecitabine (XELODA) 500 MG tab
Take 4 tabs by mouth 2 times daily. Take on Day 1 through 14., 2,000 mg (rounded from 1,960 mg = 1,000 mg/m2 ×
1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
Round doses to available tablet sizes of 500mg and 150mg
capecitabine (XELODA) 150 MG tab
Take 13 tabs by mouth 2 times daily. Take on Day 1 through 14., 1,950 mg (rounded from 1,960 mg = 1,000 mg/m2
× 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
Round doses to available tablet sizes of 500mg and 150mg.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Calcium, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: CISplatin and
trastuzumab for 120 minutes.
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
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Zztestonc,Jeff J [2507481]
8/8/2017 3:07:03 PM Page 9 of 18
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Cycle 4 –  10/10/2017 through 10/30/2017 (21 days), Planned
Day 1, Cycle 4 –  Planned for 10/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gastric/GE Junction Cancer (Advanced); THERAPY: Cycle 1: trastuzumab 8 mg/kg IV Day 1 (Loading Dose),
CISplatin 80 mg/m2 IV Day 1, capecitabine 1000 mg/m2 by mouth twice daily Day 1 through 14; Cycle 2 and all
subsequent cycles: trastuzumab 6 mg/kg IV Day 1; CISplatin 80 mg/m2 IV Day 1; capecitabine 1000 mg/m2 by mouth
twice daily Day 1 through 14; CYCLE LENGTH: 21 days; COURSE: until disease progression
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+21 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+21 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+21 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+21 Approximate, Expires: S+365, Routine
BUN
Expected: S+21 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+21 Approximate, Expires: S+365, Routine
CALCIUM
Expected: S+21 Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S+21 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, and Magnesium.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 75K/µL or Creatinine greater
than 1.5 mg/dL or Magnesium less than 1.5 mg/dL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
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Zztestonc,Jeff J [2507481]
8/8/2017 3:07:03 PM Page 10 of 18
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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.
Measure Intake And Output
SEE COMMENTS Starting when released Until Specified
Measure intake and output: If IV intake is greater than 2000 mL and urine output is less than 500 mL between start of
cisplatin and discharge, notify provider.
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)
RN instruct patient to drink 12 (8 ounce) glasses of water day of and for two days after treatment.
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 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
sodium chloride 0.9 % infusion 500 mL
at 250-500 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
POST CISPLATIN HYDRATION. Delete if not needed.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 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
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Zztestonc,Jeff J [2507481]
8/8/2017 3:07:03 PM Page 11 of 18
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
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
Hypersensitivity risk.  See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy.
Administer over 30 minutes. Patient must be monitored for one hour after the first dose of trastuzumab.
CISplatin (PLATINOL) 157 mg in sodium chloride 0.9 % 1,000 mL bag
157 mg (rounded from 156.8 mg = 80 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Administer over 60 to 90 minutes.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): capecitabine (Dispensed Day 1 of
each cycle).
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Take Home Medications (delete all that do not apply)
capecitabine (XELODA) 500 MG tab
Take 4 tabs by mouth 2 times daily. Take on Day 1 through 14., 2,000 mg (rounded from 1,960 mg = 1,000 mg/m2 ×
1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
Round doses to available tablet sizes of 500mg and 150mg
capecitabine (XELODA) 150 MG tab
Take 13 tabs by mouth 2 times daily. Take on Day 1 through 14., 1,950 mg (rounded from 1,960 mg = 1,000 mg/m2
× 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
Round doses to available tablet sizes of 500mg and 150mg.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Calcium, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: CISplatin and
trastuzumab for 120 minutes.
Cycle 5 –  10/31/2017 through 11/20/2017 (21 days), Planned
Day 1, Cycle 5 –  Planned for 10/31/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gastric/GE Junction Cancer (Advanced); THERAPY: Cycle 1: trastuzumab 8 mg/kg IV Day 1 (Loading Dose),
CISplatin 80 mg/m2 IV Day 1, capecitabine 1000 mg/m2 by mouth twice daily Day 1 through 14; Cycle 2 and all
subsequent cycles: trastuzumab 6 mg/kg IV Day 1; CISplatin 80 mg/m2 IV Day 1; capecitabine 1000 mg/m2 by mouth
twice daily Day 1 through 14; CYCLE LENGTH: 21 days; COURSE: until disease progression
Consent
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
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Zztestonc,Jeff J [2507481]
8/8/2017 3:07:03 PM Page 12 of 18
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+21 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+21 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+21 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+21 Approximate, Expires: S+365, Routine
BUN
Expected: S+21 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+21 Approximate, Expires: S+365, Routine
CALCIUM
Expected: S+21 Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S+21 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, and Magnesium.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 75K/µL or Creatinine greater
than 1.5 mg/dL or Magnesium less than 1.5 mg/dL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to trastuzumab can occur.  For first and second dose, patient should be treated in a location to
optimize emergency care. Patient must be monitored for one hour after the first dose of trastuzumab. See Emergency
Medications.
Measure Intake And Output
SEE COMMENTS Starting when released Until Specified
Measure intake and output: If IV intake is greater than 2000 mL and urine output is less than 500 mL between start of
cisplatin and discharge, notify provider.
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)
RN instruct patient to drink 12 (8 ounce) glasses of water day of and for two days after treatment.
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Zztestonc,Jeff J [2507481]
8/8/2017 3:07:03 PM Page 13 of 18
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.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
sodium chloride 0.9 % infusion 500 mL
at 250-500 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
POST CISPLATIN HYDRATION. Delete if not needed.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 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) 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
Hypersensitivity risk.  See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy.
Administer over 30 minutes. Patient must be monitored for one hour after the first dose of trastuzumab.
CISplatin (PLATINOL) 157 mg in sodium chloride 0.9 % 1,000 mL bag
157 mg (rounded from 156.8 mg = 80 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Administer over 60 to 90 minutes.
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Zztestonc,Jeff J [2507481]
8/8/2017 3:07:03 PM Page 14 of 18
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): capecitabine
(Dispensed Day 1 of each cycle).
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Take Home Medications (delete all that do not apply)
capecitabine (XELODA) 500 MG tab
Take 4 tabs by mouth 2 times daily. Take on Day 1 through 14., 2,000 mg (rounded from 1,960 mg = 1,000 mg/m2 ×
1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
Round doses to available tablet sizes of 500mg and 150mg
capecitabine (XELODA) 150 MG tab
Take 13 tabs by mouth 2 times daily. Take on Day 1 through 14., 1,950 mg (rounded from 1,960 mg = 1,000 mg/m2
× 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
Round doses to available tablet sizes of 500mg and 150mg.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Calcium, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: CISplatin and
trastuzumab for 120 minutes.
Cycle 6 –  11/21/2017 through 12/11/2017 (21 days), Planned
Day 1, Cycle 6 –  Planned for 11/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gastric/GE Junction Cancer (Advanced); THERAPY: Cycle 1: trastuzumab 8 mg/kg IV Day 1 (Loading Dose),
CISplatin 80 mg/m2 IV Day 1, capecitabine 1000 mg/m2 by mouth twice daily Day 1 through 14; Cycle 2 and all
subsequent cycles: trastuzumab 6 mg/kg IV Day 1; CISplatin 80 mg/m2 IV Day 1; capecitabine 1000 mg/m2 by mouth
twice daily Day 1 through 14; CYCLE LENGTH: 21 days; COURSE: until disease progression
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
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Zztestonc,Jeff J [2507481]
8/8/2017 3:07:03 PM Page 15 of 18
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Expected: S+21 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+21 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+21 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+21 Approximate, Expires: S+365, Routine
BUN
Expected: S+21 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+21 Approximate, Expires: S+365, Routine
CALCIUM
Expected: S+21 Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S+21 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, and Magnesium.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 75K/µL or Creatinine greater
than 1.5 mg/dL or Magnesium less than 1.5 mg/dL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to trastuzumab can occur.  For first and second dose, patient should be treated in a location to
optimize emergency care. Patient must be monitored for one hour after the first dose of trastuzumab. See Emergency
Medications.
Measure Intake And Output
SEE COMMENTS Starting when released Until Specified
Measure intake and output: If IV intake is greater than 2000 mL and urine output is less than 500 mL between start of
cisplatin and discharge, notify provider.
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)
RN instruct patient to drink 12 (8 ounce) glasses of water day of and for two days after treatment.
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
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Zztestonc,Jeff J [2507481]
8/8/2017 3:07:03 PM Page 16 of 18
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
sodium chloride 0.9 % infusion 500 mL
at 250-500 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
POST CISPLATIN HYDRATION. Delete if not needed.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 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) 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
Hypersensitivity risk.  See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy.
Administer over 30 minutes. Patient must be monitored for one hour after the first dose of trastuzumab.
CISplatin (PLATINOL) 157 mg in sodium chloride 0.9 % 1,000 mL bag
157 mg (rounded from 156.8 mg = 80 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Administer over 60 to 90 minutes.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): capecitabine (Dispensed Day 1 of
each cycle).
Conditional Orders
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN, 1 dose Starting when released, edema
IV push rate 10 mg/minute.
Administer if intake is greater than 2000 mL and urine output less than 500 mL.
Take Home Medications (delete all that do not apply)
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Zztestonc,Jeff J [2507481]
8/8/2017 3:07:03 PM Page 17 of 18
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

capecitabine (XELODA) 500 MG tab
Take 4 tabs by mouth 2 times daily. Take on Day 1 through 14., 2,000 mg (rounded from 1,960 mg
= 1,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
Round doses to available tablet sizes of 500mg and 150mg
capecitabine (XELODA) 150 MG tab
Take 13 tabs by mouth 2 times daily. Take on Day 1 through 14., 1,950 mg (rounded from 1,960 mg = 1,000 mg/m2
× 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
Round doses to available tablet sizes of 500mg and 150mg.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Calcium, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: CISplatin and
trastuzumab for 120 minutes.
This medication will not be e-prescribed. If patient is present, script will go to printer.
Otherwise, script will go to nursing or tech pool.   Invalid items: Pharmacy   
Details...
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
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Zztestonc,Jeff J [2507481]
8/8/2017 3:07:03 PM Page 18 of 18
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org