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CSC GI Cisplatin(21D:1) Fluorouracil(21D:1-5) Trastuzumab(21D:1) VER 8-15-17(HL 4398)

CSC GI Cisplatin(21D:1) Fluorouracil(21D:1-5) Trastuzumab(21D:1) VER 8-15-17(HL 4398) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GI


CSC GI CISPLATIN(21D:1)/FLUOROURACIL(21D:1-5)/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 on Day 1, fluorouracil dose = 800 mg/m2/day administered as a continuous infusion IV over 120
hours on Day 1 through 5 (total dose = 4000 mg/m2 IV over 120 hours); Cycle 2 and all subsequent cycles: trastuzumab
6 mg/kg IV Day 1, CISplatin 80 mg/m2 IV on Day 1, fluorouracil dose = 800 mg/m2/day administered as a continuous
infusion IV over 120 hours on Day 1 through 5 (total dose = 4000 mg/m2 IV over 120 hours); 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
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Take Home Medications
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
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Zztestonc,Jeff J [2507481]
8/8/2017 3:05:13 PM Page 1 of 21
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Cycle 1 –  8/8/2017 through 8/28/2017 (21 days), Planned
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 on Day 1, fluorouracil dose = 800 mg/m2/day administered as a continuous infusion IV over 120
hours on Day 1 through 5 (total dose = 4000 mg/m2 IV over 120 hours); Cycle 2 and all subsequent cycles: trastuzumab
6 mg/kg IV Day 1, CISplatin 80 mg/m2 IV on Day 1, fluorouracil dose = 800 mg/m2/day administered as a continuous
infusion IV over 120 hours on Day 1 through 5 (total dose = 4000 mg/m2 IV over 120 hours); 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.
Page Or Call ___________
Notify Home infusion 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
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Zztestonc,Jeff J [2507481]
8/8/2017 3:05:13 PM Page 2 of 21
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 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
POST-CISPLATIN HYDRATION. Delete if not needed.
Pre-Medications
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
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.
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Zztestonc,Jeff J [2507481]
8/8/2017 3:05:13 PM Page 3 of 21
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

fluorouracil (ADRUCIL) home infusion bag 7,840 mg
7,840 mg (4,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
Five Day Infusion: Fluorouracil Dose = 800 mg/m2/DAY administered as a single continuous infusion IV
over 5 days. (Total dose = 4000 mg/m2 IV over 5 days).
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.
Follow-Up
DAY 6 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Calcium, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: CISplatin,
fluorouracil and trastuzumab for 180 minutes.
Day 6 (Pump Disconnect), Cycle 1 –  Planned for 8/13/2017
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 on Day 1, fluorouracil dose = 800 mg/m2/day administered as a continuous infusion IV over 120
hours on Day 1 through 5 (total dose = 4000 mg/m2 IV over 120 hours); Cycle 2 and all subsequent cycles: trastuzumab
6 mg/kg IV Day 1, CISplatin 80 mg/m2 IV on Day 1, fluorouracil dose = 800 mg/m2/day administered as a continuous
infusion IV over 120 hours on Day 1 through 5 (total dose = 4000 mg/m2 IV over 120 hours); CYCLE LENGTH: 21 days;
COURSE: until disease progression
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 120-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 –  8/29/2017 through 9/18/2017 (21 days), Planned
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Zztestonc,Jeff J [2507481]
8/8/2017 3:05:13 PM Page 4 of 21
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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 on Day 1, fluorouracil dose = 800 mg/m2/day administered as a continuous infusion IV over 120
hours on Day 1 through 5 (total dose = 4000 mg/m2 IV over 120 hours); Cycle 2 and all subsequent cycles: trastuzumab
6 mg/kg IV Day 1, CISplatin 80 mg/m2 IV on Day 1, fluorouracil dose = 800 mg/m2/day administered as a continuous
infusion IV over 120 hours on Day 1 through 5 (total dose = 4000 mg/m2 IV over 120 hours); 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 3:05:13 PM Page 5 of 21
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.
Page Or Call ___________
Notify Home infusion 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
at 250-500 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
POST-CISPLATIN HYDRATION. Delete if not needed.
Pre-Medications
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
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
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Zztestonc,Jeff J [2507481]
8/8/2017 3:05:13 PM Page 6 of 21
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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.
fluorouracil (ADRUCIL) home infusion bag 7,840 mg
7,840 mg (4,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Five Day Infusion: Fluorouracil Dose = 800 mg/m2/DAY administered as a single continuous infusion IV over 5 days.
(Total dose = 4000 mg/m2 IV over 5 days).
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.
Follow-Up
DAY 6 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Calcium, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: CISplatin,
fluorouracil and trastuzumab for 150 minutes.
Day 6 (Pump Disconnect), Cycle 2 –  Planned for 9/3/2017
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 on Day 1, fluorouracil dose = 800 mg/m2/day administered as a continuous infusion IV over 120
hours on Day 1 through 5 (total dose = 4000 mg/m2 IV over 120 hours); Cycle 2 and all subsequent cycles: trastuzumab
6 mg/kg IV Day 1, CISplatin 80 mg/m2 IV on Day 1, fluorouracil dose = 800 mg/m2/day administered as a continuous
infusion IV over 120 hours on Day 1 through 5 (total dose = 4000 mg/m2 IV over 120 hours); CYCLE LENGTH: 21 days;
COURSE: until disease progression
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
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Zztestonc,Jeff J [2507481]
8/8/2017 3:05:13 PM Page 7 of 21
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.
Treatment Medications
Pump Disconnection Procedures
Disconnect pump upon completion of 120-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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 on Day 1, fluorouracil dose = 800 mg/m2/day administered as a continuous infusion IV over 120
hours on Day 1 through 5 (total dose = 4000 mg/m2 IV over 120 hours); Cycle 2 and all subsequent cycles: trastuzumab
6 mg/kg IV Day 1, CISplatin 80 mg/m2 IV on Day 1, fluorouracil dose = 800 mg/m2/day administered as a continuous
infusion IV over 120 hours on Day 1 through 5 (total dose = 4000 mg/m2 IV over 120 hours); 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
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Zztestonc,Jeff J [2507481]
8/8/2017 3:05:13 PM Page 8 of 21
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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.
Page Or Call ___________
Notify Home infusion 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
at 250-500 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
POST-CISPLATIN HYDRATION. Delete if not needed.
Pre-Medications
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Zztestonc,Jeff J [2507481]
8/8/2017 3:05:13 PM Page 9 of 21
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
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.
fluorouracil (ADRUCIL) home infusion bag 7,840 mg
7,840 mg (4,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Five Day Infusion: Fluorouracil Dose = 800 mg/m2/DAY administered as a single continuous infusion IV over 5 days.
(Total dose = 4000 mg/m2 IV over 5 days).
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.
Follow-Up
DAY 6 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Calcium, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: CISplatin,
fluorouracil and trastuzumab for 150 minutes.
Day 6 (Pump Disconnect), Cycle 3 –  Planned for 9/24/2017
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Zztestonc,Jeff J [2507481]
8/8/2017 3:05:13 PM Page 10 of 21
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: Gastric/GE Junction Cancer (Advanced); THERAPY: Cycle 1: trastuzumab 8 mg/kg IV Day 1 (Loading Dose),
CISplatin 80 mg/m2 IV on Day 1, fluorouracil dose = 800 mg/m2/day administered as a continuous infusion IV over 120
hours on Day 1 through 5 (total dose = 4000 mg/m2 IV over 120 hours); Cycle 2 and all subsequent cycles: trastuzumab
6 mg/kg IV Day 1, CISplatin 80 mg/m2 IV on Day 1, fluorouracil dose = 800 mg/m2/day administered as a continuous
infusion IV over 120 hours on Day 1 through 5 (total dose = 4000 mg/m2 IV over 120 hours); CYCLE LENGTH: 21 days;
COURSE: until disease progression
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 120-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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 on Day 1, fluorouracil dose = 800 mg/m2/day administered as a continuous infusion IV over 120
hours on Day 1 through 5 (total dose = 4000 mg/m2 IV over 120 hours); Cycle 2 and all subsequent cycles: trastuzumab
6 mg/kg IV Day 1, CISplatin 80 mg/m2 IV on Day 1, fluorouracil dose = 800 mg/m2/day administered as a continuous
infusion IV over 120 hours on Day 1 through 5 (total dose = 4000 mg/m2 IV over 120 hours); 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.
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Zztestonc,Jeff J [2507481]
8/8/2017 3:05:13 PM Page 11 of 21
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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.
Page Or Call ___________
Notify Home infusion 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.
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Zztestonc,Jeff J [2507481]
8/8/2017 3:05:13 PM Page 12 of 21
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 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
POST-CISPLATIN HYDRATION. Delete if not needed.
Pre-Medications
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
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.
fluorouracil (ADRUCIL) home infusion bag 7,840 mg
7,840 mg (4,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Five Day Infusion: Fluorouracil Dose = 800 mg/m2/DAY administered as a single continuous infusion IV over 5 days.
(Total dose = 4000 mg/m2 IV over 5 days).
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Zztestonc,Jeff J [2507481]
8/8/2017 3:05:13 PM Page 13 of 21
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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.
Follow-Up
DAY 6 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Calcium, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: CISplatin,
fluorouracil and trastuzumab for 150 minutes.
Day 6 (Pump Disconnect), Cycle 4 –  Planned for 10/15/2017
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 on Day 1, fluorouracil dose = 800 mg/m2/day administered as a continuous infusion IV over 120
hours on Day 1 through 5 (total dose = 4000 mg/m2 IV over 120 hours); Cycle 2 and all subsequent cycles: trastuzumab
6 mg/kg IV Day 1, CISplatin 80 mg/m2 IV on Day 1, fluorouracil dose = 800 mg/m2/day administered as a continuous
infusion IV over 120 hours on Day 1 through 5 (total dose = 4000 mg/m2 IV over 120 hours); CYCLE LENGTH: 21 days;
COURSE: until disease progression
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 120-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 –  10/31/2017 through 11/20/2017 (21 days), Planned
Day 1, Cycle 5 –  Planned for 10/31/2017
Treatment Plan Information
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Zztestonc,Jeff J [2507481]
8/8/2017 3:05:13 PM Page 14 of 21
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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 on Day 1, fluorouracil dose = 800 mg/m2/day administered as
a continuous infusion IV over 120 hours on Day 1 through 5 (total dose = 4000 mg/m2 IV over 120
hours); Cycle 2 and all subsequent cycles: trastuzumab 6 mg/kg IV Day 1, CISplatin 80 mg/m2 IV on
Day 1, fluorouracil dose = 800 mg/m2/day administered as a continuous infusion IV over 120 hours on
Day 1 through 5 (total dose = 4000 mg/m2 IV over 120 hours); 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)
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
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Zztestonc,Jeff J [2507481]
8/8/2017 3:05:13 PM Page 15 of 21
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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.
Page Or Call ___________
Notify Home infusion 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
at 250-500 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
POST-CISPLATIN HYDRATION. Delete if not needed.
Pre-Medications
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
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 3:05:13 PM Page 16 of 21
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.
fluorouracil (ADRUCIL) home infusion bag 7,840 mg
7,840 mg (4,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Five Day Infusion: Fluorouracil Dose = 800 mg/m2/DAY administered as a single continuous infusion IV over 5 days.
(Total dose = 4000 mg/m2 IV over 5 days).
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.
Follow-Up
DAY 6 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Calcium, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: CISplatin,
fluorouracil and trastuzumab for 150 minutes.
Day 6 (Pump Disconnect), Cycle 5 –  Planned for 11/5/2017
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 on Day 1, fluorouracil dose = 800 mg/m2/day administered as a continuous infusion IV over 120
hours on Day 1 through 5 (total dose = 4000 mg/m2 IV over 120 hours); Cycle 2 and all subsequent cycles: trastuzumab
6 mg/kg IV Day 1, CISplatin 80 mg/m2 IV on Day 1, fluorouracil dose = 800 mg/m2/day administered as a continuous
infusion IV over 120 hours on Day 1 through 5 (total dose = 4000 mg/m2 IV over 120 hours); CYCLE LENGTH: 21 days;
COURSE: until disease progression
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
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Zztestonc,Jeff J [2507481]
8/8/2017 3:05:13 PM Page 17 of 21
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.
Treatment Medications
Pump Disconnection Procedures
Disconnect pump upon completion of 120-hour fluorouracil infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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 on Day 1, fluorouracil dose = 800 mg/m2/day administered as a continuous infusion IV over 120
hours on Day 1 through 5 (total dose = 4000 mg/m2 IV over 120 hours); Cycle 2 and all subsequent cycles: trastuzumab
6 mg/kg IV Day 1, CISplatin 80 mg/m2 IV on Day 1, fluorouracil dose = 800 mg/m2/day administered as a continuous
infusion IV over 120 hours on Day 1 through 5 (total dose = 4000 mg/m2 IV over 120 hours); 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
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Zztestonc,Jeff J [2507481]
8/8/2017 3:05:13 PM Page 18 of 21
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.
Page Or Call ___________
Notify Home infusion 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
at 250-500 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
POST-CISPLATIN HYDRATION. Delete if not needed.
Pre-Medications
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
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Zztestonc,Jeff J [2507481]
8/8/2017 3:05:13 PM Page 19 of 21
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
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.
fluorouracil (ADRUCIL) home infusion bag 7,840 mg
7,840 mg (4,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Five Day Infusion: Fluorouracil Dose = 800 mg/m2/DAY administered as a single continuous infusion IV over 5 days.
(Total dose = 4000 mg/m2 IV over 5 days).
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.
Follow-Up
DAY 6 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Calcium, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: CISplatin,
fluorouracil and trastuzumab for 150 minutes.
Day 6 (Pump Disconnect), Cycle 6 –  Planned for 11/26/2017
Treatment Plan Information
Treatment Plan Summary
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Zztestonc,Jeff J [2507481]
8/8/2017 3:05:13 PM Page 20 of 21
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

DISEASE: Gastric/GE Junction Cancer (Advanced); THERAPY: Cycle 1: trastuzumab 8 mg/kg IV Day 1 (Loading Dose),
CISplatin 80 mg/m2 IV on Day 1, fluorouracil dose = 800 mg/m2/day administered as a continuous infusion IV over 120
hours on Day 1 through 5 (total dose = 4000 mg/m2 IV over 120 hours); Cycle 2 and all subsequent cycles: trastuzumab
6 mg/kg IV Day 1, CISplatin 80 mg/m2 IV on Day 1, fluorouracil dose = 800 mg/m2/day administered as a continuous
infusion IV over 120 hours on Day 1 through 5 (total dose = 4000 mg/m2 IV over 120 hours); CYCLE LENGTH: 21 days;
COURSE: until disease progression
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 120-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]
8/8/2017 3:05:13 PM Page 21 of 21
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org