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CSC GI Ramucirumab(28D:1,15) VER 8-15-17 (HL 5336)

CSC GI Ramucirumab(28D:1,15) VER 8-15-17 (HL 5336) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GI


CSC GI RAMUCIRUMAB(28D:1,15) VER: 8-15-17 –  Properties
Pre-Cycle –  8/3/2017 through 8/9/2017 (7 days), Planned
Day 1, Pre-Cycle –  Planned for 8/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gastric and Gastro-esophageal Junction Adenocarcinoma (Advanced); THERAPY: ramucirumab 8 mg/kg IV Day
1 and Day 15; CYCLE LENGTH: 28 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
CREATININE
Expected: S Approximate, Expires: S+365, Routine
BUN
Expected: S Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S Approximate, Expires: S+365, Normal, Routine
URINALYSIS, NO MICROSCOPY
Expected: S Approximate, Expires: S+365, Normal, Routine
Cycle 1 –  8/10/2017 through 9/6/2017 (28 days), Planned
Day 1, Cycle 1 –  Planned for 8/10/2017
Treatment Plan Information
Reference Information (1)
GASTRIC AND GASTRO-ESOPHAGEAL JUNCTION ADENOCARCINOMA: Fuchs CS, et al. Lancet 2014;383:31-9.
Treatment Plan Summary
DISEASE: Gastric and Gastro-esophageal Junction Adenocarcinoma (Advanced); THERAPY: ramucirumab 8 mg/kg IV Day
1 and Day 15; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Consent
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Zztestonc,Jeff J [2507481]
8/10/2017 9:42:16 AM Page 1 of 24
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.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: Urinalysis without Microscopy.
Treatment Parameters
Hold and notify authorizing prescriber for Urine Protein greater than 100 mg/dL or Blood Pressure greater than 160/90
mmHg.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to ramucirumab can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Vital Signs
ONCE Starting when released
Obtain Blood Pressure, Heart Rate, Respiratory Rate and Temperature
Patient Instructions(1)
Advise patients to report any bleeding or symptoms of bleeding.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to treatment.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Emergency Medications
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Zztestonc,Jeff J [2507481]
8/10/2017 9:42:16 AM Page 2 of 24
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
ramucirumab 648 mg in sodium chloride 0.9 % 250 mL bag
648 mg (8 mg/kg × 81 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer with 0.2 or 0.22 micron filter over 60 minutes. DO NOT dilute with other solutions or co-infuse with other
electrolytes or medications. Hypersensitivity reaction to ramucirumab can occur.  For first and second dose, patient
should be treated in a location to optimize emergency care. See Emergency Medications.
NOTE: Round to nearest 100 mg.
Follow-Up
DAY 15 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: ramucirumab infusion for 90 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Creatinine, BUN, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Urinalysis without microscopy; CHEMOTHERAPY ROOM
APPOINTMENT: ramucirumab for 90 minutes.
Day 15, Cycle 1 –  Planned for 8/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gastric and Gastro-esophageal Junction Adenocarcinoma (Advanced); THERAPY: ramucirumab 8 mg/kg IV Day
1 and Day 15; CYCLE LENGTH: 28 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Treatment Parameters
Hold and notify authorizing prescriber for Blood Pressure greater than 160/90 mmHg.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to ramucirumab can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Vital Signs
ONCE Starting when released
Obtain Blood Pressure, Heart Rate, Respiratory Rate and Temperature
Patient Instructions(1)
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Zztestonc,Jeff J [2507481]
8/10/2017 9:42:16 AM Page 3 of 24
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Advise patients to report any bleeding or symptoms of bleeding.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to treatment.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Pre-Medications (delete all that do not apply)
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer prior to chemotherapy. For use in patients who have previously reacted to ramucirumab.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy. For use in patients who have previously reacted to ramucirumab. No more than 4
grams acetaminophen per 24 hours for adults or 15mg/kg per dose for peds <40kg.
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
ramucirumab 648 mg in sodium chloride 0.9 % 250 mL bag
648 mg (8 mg/kg × 81 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer with 0.2 or 0.22 micron filter over 60 minutes. DO NOT dilute with other solutions or co-infuse with other
electrolytes or medications. Hypersensitivity reaction to ramucirumab can occur.  For first and second dose, patient
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Zztestonc,Jeff J [2507481]
8/10/2017 9:42:16 AM Page 4 of 24
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

should be treated in a location to optimize emergency care. See Emergency Medications.
NOTE: Round to nearest 100 mg.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 –  9/7/2017 through 10/4/2017 (28 days), Planned
Day 1, Cycle 2 –  Planned for 9/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gastric and Gastro-esophageal Junction Adenocarcinoma (Advanced); THERAPY: ramucirumab 8 mg/kg IV Day
1 and Day 15; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+14 Approximate, Expires: S+365, Routine
BUN
Expected: S+14 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
URINALYSIS, NO MICROSCOPY
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
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Zztestonc,Jeff J [2507481]
8/10/2017 9:42:16 AM Page 5 of 24
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Verify pretreatment labs have been obtained and resulted: Urinalysis without Microscopy.
Treatment Parameters
Hold and notify authorizing prescriber for Urine Protein greater than 100 mg/dL or Blood Pressure greater than 160/90
mmHg.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to ramucirumab can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Vital Signs
ONCE Starting when released
Obtain Blood Pressure, Heart Rate, Respiratory Rate and Temperature
Patient Instructions(1)
Advise patients to report any bleeding or symptoms of bleeding.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to treatment.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Pre-Medications (delete all that do not apply)
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer prior to chemotherapy. For use in patients who have previously reacted to ramucirumab.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy. For use in patients who have previously reacted to ramucirumab. No more than 4
grams acetaminophen per 24 hours for adults or 15mg/kg per dose for peds <40kg.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
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Zztestonc,Jeff J [2507481]
8/10/2017 9:42:16 AM Page 6 of 24
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
ramucirumab 648 mg in sodium chloride 0.9 % 250 mL bag
648 mg (8 mg/kg × 81 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer with 0.2 or 0.22 micron filter over 60 minutes. DO NOT dilute with other solutions or co-infuse with other
electrolytes or medications. Hypersensitivity reaction to ramucirumab can occur.  For first and second dose, patient
should be treated in a location to optimize emergency care. See Emergency Medications.
NOTE: Round to nearest 100 mg.
Follow-Up
DAY 15 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: ramucirumab infusion for 90 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Creatinine, BUN, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Urinalysis without microscopy; CHEMOTHERAPY ROOM
APPOINTMENT: ramucirumab for 90 minutes.
Day 15, Cycle 2 –  Planned for 9/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gastric and Gastro-esophageal Junction Adenocarcinoma (Advanced); THERAPY: ramucirumab 8 mg/kg IV Day
1 and Day 15; CYCLE LENGTH: 28 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Treatment Parameters
Hold and notify authorizing prescriber for Blood Pressure greater than 160/90 mmHg.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to ramucirumab can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Vital Signs
ONCE Starting when released
Obtain Blood Pressure, Heart Rate, Respiratory Rate and Temperature
Patient Instructions(1)
Advise patients to report any bleeding or symptoms of bleeding.
Flush Venous Access Device per Guidelines
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Zztestonc,Jeff J [2507481]
8/10/2017 9:42:16 AM Page 7 of 24
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to treatment.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Pre-Medications (delete all that do not apply)
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer prior to chemotherapy. For use in patients who have previously reacted to ramucirumab.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy. For use in patients who have previously reacted to ramucirumab. No more than 4
grams acetaminophen per 24 hours for adults or 15mg/kg per dose for peds <40kg.
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
ramucirumab 648 mg in sodium chloride 0.9 % 250 mL bag
648 mg (8 mg/kg × 81 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer with 0.2 or 0.22 micron filter over 60 minutes. DO NOT dilute with other solutions or co-infuse with other
electrolytes or medications. Hypersensitivity reaction to ramucirumab can occur.  For first and second dose, patient
should be treated in a location to optimize emergency care. See Emergency Medications.
NOTE: Round to nearest 100 mg.
Follow-Up
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Zztestonc,Jeff J [2507481]
8/10/2017 9:42:16 AM Page 8 of 24
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 –  10/5/2017 through 11/1/2017 (28 days), Planned
Day 1, Cycle 3 –  Planned for 10/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gastric and Gastro-esophageal Junction Adenocarcinoma (Advanced); THERAPY: ramucirumab 8 mg/kg IV Day
1 and Day 15; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+14 Approximate, Expires: S+365, Routine
BUN
Expected: S+14 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
URINALYSIS, NO MICROSCOPY
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: Urinalysis without Microscopy.
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Zztestonc,Jeff J [2507481]
8/10/2017 9:42:16 AM Page 9 of 24
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Treatment Parameters
Hold and notify authorizing prescriber for Urine Protein greater than 100 mg/dL or Blood Pressure
greater than 160/90 mmHg.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to ramucirumab can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Vital Signs
ONCE Starting when released
Obtain Blood Pressure, Heart Rate, Respiratory Rate and Temperature
Patient Instructions(1)
Advise patients to report any bleeding or symptoms of bleeding.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to treatment.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Pre-Medications (delete all that do not apply)
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer prior to chemotherapy. For use in patients who have previously reacted to ramucirumab.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy. For use in patients who have previously reacted to ramucirumab. No more than 4
grams acetaminophen per 24 hours for adults or 15mg/kg per dose for peds <40kg.
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
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Zztestonc,Jeff J [2507481]
8/10/2017 9:42:16 AM Page 10 of 24
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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
ramucirumab 648 mg in sodium chloride 0.9 % 250 mL bag
648 mg (8 mg/kg × 81 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer with 0.2 or 0.22 micron filter over 60 minutes. DO NOT dilute with other solutions or co-infuse with other
electrolytes or medications. Hypersensitivity reaction to ramucirumab can occur.  For first and second dose, patient
should be treated in a location to optimize emergency care. See Emergency Medications.
NOTE: Round to nearest 100 mg.
Follow-Up
DAY 15 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: ramucirumab infusion for 90 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Creatinine, BUN, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Urinalysis without microscopy; CHEMOTHERAPY ROOM
APPOINTMENT: ramucirumab for 90 minutes.
Day 15, Cycle 3 –  Planned for 10/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gastric and Gastro-esophageal Junction Adenocarcinoma (Advanced); THERAPY: ramucirumab 8 mg/kg IV Day
1 and Day 15; CYCLE LENGTH: 28 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Treatment Parameters
Hold and notify authorizing prescriber for Blood Pressure greater than 160/90 mmHg.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to ramucirumab can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Vital Signs
ONCE Starting when released
Obtain Blood Pressure, Heart Rate, Respiratory Rate and Temperature
Patient Instructions(1)
Advise patients to report any bleeding or symptoms of bleeding.
Flush Venous Access Device per Guidelines
Order details
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Zztestonc,Jeff J [2507481]
8/10/2017 9:42:16 AM Page 11 of 24
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to treatment.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Pre-Medications (delete all that do not apply)
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer prior to chemotherapy. For use in patients who have previously reacted to ramucirumab.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy. For use in patients who have previously reacted to ramucirumab. No more than 4
grams acetaminophen per 24 hours for adults or 15mg/kg per dose for peds <40kg.
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
ramucirumab 648 mg in sodium chloride 0.9 % 250 mL bag
648 mg (8 mg/kg × 81 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer with 0.2 or 0.22 micron filter over 60 minutes. DO NOT dilute with other solutions or co-infuse with other
electrolytes or medications. Hypersensitivity reaction to ramucirumab can occur.  For first and second dose, patient
should be treated in a location to optimize emergency care. See Emergency Medications.
NOTE: Round to nearest 100 mg.
Follow-Up
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Zztestonc,Jeff J [2507481]
8/10/2017 9:42:16 AM Page 12 of 24
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 –  11/2/2017 through 11/29/2017 (28 days), Planned
Day 1, Cycle 4 –  Planned for 11/2/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gastric and Gastro-esophageal Junction Adenocarcinoma (Advanced); THERAPY: ramucirumab 8 mg/kg IV Day
1 and Day 15; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+14 Approximate, Expires: S+365, Routine
BUN
Expected: S+14 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
URINALYSIS, NO MICROSCOPY
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: Urinalysis without Microscopy.
Treatment Parameters
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Zztestonc,Jeff J [2507481]
8/10/2017 9:42:16 AM Page 13 of 24
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Hold and notify authorizing prescriber for Urine Protein greater than 100 mg/dL or Blood Pressure greater than 160/90
mmHg.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to ramucirumab can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Vital Signs
ONCE Starting when released
Obtain Blood Pressure, Heart Rate, Respiratory Rate and Temperature
Patient Instructions(1)
Advise patients to report any bleeding or symptoms of bleeding.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to treatment.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Pre-Medications (delete all that do not apply)
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer prior to chemotherapy. For use in patients who have previously reacted to ramucirumab.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy. For use in patients who have previously reacted to ramucirumab. No more than 4
grams acetaminophen per 24 hours for adults or 15mg/kg per dose for peds <40kg.
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]
8/10/2017 9:42:16 AM Page 14 of 24
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
ramucirumab 648 mg in sodium chloride 0.9 % 250 mL bag
648 mg (8 mg/kg × 81 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer with 0.2 or 0.22 micron filter over 60 minutes. DO NOT dilute with other solutions or co-infuse with other
electrolytes or medications. Hypersensitivity reaction to ramucirumab can occur.  For first and second dose, patient
should be treated in a location to optimize emergency care. See Emergency Medications.
NOTE: Round to nearest 100 mg.
Follow-Up
DAY 15 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: ramucirumab infusion for 90 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Creatinine, BUN, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Urinalysis without microscopy; CHEMOTHERAPY ROOM
APPOINTMENT: ramucirumab for 90 minutes.
Day 15, Cycle 4 –  Planned for 11/16/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gastric and Gastro-esophageal Junction Adenocarcinoma (Advanced); THERAPY: ramucirumab 8 mg/kg IV Day
1 and Day 15; CYCLE LENGTH: 28 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Treatment Parameters
Hold and notify authorizing prescriber for Blood Pressure greater than 160/90 mmHg.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to ramucirumab can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Vital Signs
ONCE Starting when released
Obtain Blood Pressure, Heart Rate, Respiratory Rate and Temperature
Patient Instructions(1)
Advise patients to report any bleeding or symptoms of bleeding.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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Zztestonc,Jeff J [2507481]
8/10/2017 9:42:16 AM Page 15 of 24
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to treatment.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Pre-Medications (delete all that do not apply)
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer prior to chemotherapy. For use in patients who have previously reacted to ramucirumab.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy. For use in patients who have previously reacted to ramucirumab. No more than 4
grams acetaminophen per 24 hours for adults or 15mg/kg per dose for peds <40kg.
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
ramucirumab 648 mg in sodium chloride 0.9 % 250 mL bag
648 mg (8 mg/kg × 81 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer with 0.2 or 0.22 micron filter over 60 minutes. DO NOT dilute with other solutions or co-infuse with other
electrolytes or medications. Hypersensitivity reaction to ramucirumab can occur.  For first and second dose, patient
should be treated in a location to optimize emergency care. See Emergency Medications.
NOTE: Round to nearest 100 mg.
Follow-Up
VERIFY APPOINTMENTS
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Zztestonc,Jeff J [2507481]
8/10/2017 9:42:16 AM Page 16 of 24
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 –  11/30/2017 through 12/27/2017 (28 days), Planned
Day 1, Cycle 5 –  Planned for 11/30/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gastric and Gastro-esophageal Junction Adenocarcinoma (Advanced); THERAPY: ramucirumab 8 mg/kg IV Day
1 and Day 15; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+14 Approximate, Expires: S+365, Routine
BUN
Expected: S+14 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
URINALYSIS, NO MICROSCOPY
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: Urinalysis without Microscopy.
Treatment Parameters
Hold and notify authorizing prescriber for Urine Protein greater than 100 mg/dL or Blood Pressure greater than 160/90
mmHg.
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Zztestonc,Jeff J [2507481]
8/10/2017 9:42:16 AM Page 17 of 24
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to ramucirumab can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Vital Signs
ONCE Starting when released
Obtain Blood Pressure, Heart Rate, Respiratory Rate and Temperature
Patient Instructions(1)
Advise patients to report any bleeding or symptoms of bleeding.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to treatment.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Pre-Medications (delete all that do not apply)
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer prior to chemotherapy. For use in patients who have previously reacted to ramucirumab.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy. For use in patients who have previously reacted to ramucirumab. No more than 4
grams acetaminophen per 24 hours for adults or 15mg/kg per dose for peds <40kg.
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
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Zztestonc,Jeff J [2507481]
8/10/2017 9:42:16 AM Page 18 of 24
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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
ramucirumab 648 mg in sodium chloride 0.9 % 250 mL bag
648 mg (8 mg/kg × 81 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer with 0.2 or 0.22 micron filter over 60 minutes. DO NOT dilute with other solutions or co-infuse with other
electrolytes or medications. Hypersensitivity reaction to ramucirumab can occur.  For first and second dose, patient
should be treated in a location to optimize emergency care. See Emergency Medications.
NOTE: Round to nearest 100 mg.
Follow-Up
DAY 15 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: ramucirumab infusion for 90 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Creatinine, BUN, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Urinalysis without microscopy; CHEMOTHERAPY ROOM
APPOINTMENT: ramucirumab for 90 minutes.
Day 15, Cycle 5 –  Planned for 12/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gastric and Gastro-esophageal Junction Adenocarcinoma (Advanced); THERAPY: ramucirumab 8 mg/kg IV Day
1 and Day 15; CYCLE LENGTH: 28 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Treatment Parameters
Hold and notify authorizing prescriber for Blood Pressure greater than 160/90 mmHg.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to ramucirumab can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Vital Signs
ONCE Starting when released
Obtain Blood Pressure, Heart Rate, Respiratory Rate and Temperature
Patient Instructions(1)
Advise patients to report any bleeding or symptoms of bleeding.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
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Zztestonc,Jeff J [2507481]
8/10/2017 9:42:16 AM Page 19 of 24
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to treatment.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Pre-Medications (delete all that do not apply)
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer prior to chemotherapy. For use in patients who have previously reacted to ramucirumab.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy. For use in patients who have previously reacted to ramucirumab. No more than 4
grams acetaminophen per 24 hours for adults or 15mg/kg per dose for peds <40kg.
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
ramucirumab 648 mg in sodium chloride 0.9 % 250 mL bag
648 mg (8 mg/kg × 81 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer with 0.2 or 0.22 micron filter over 60 minutes. DO NOT dilute with other solutions or co-infuse with other
electrolytes or medications. Hypersensitivity reaction to ramucirumab can occur.  For first and second dose, patient
should be treated in a location to optimize emergency care. See Emergency Medications.
NOTE: Round to nearest 100 mg.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,Jeff J [2507481]
8/10/2017 9:42:16 AM Page 20 of 24
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Cycle 6 –  12/28/2017 through 1/24/2018 (28 days), Planned
Day 1, Cycle 6 –  Planned for 12/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gastric and Gastro-esophageal Junction Adenocarcinoma (Advanced); THERAPY: ramucirumab 8 mg/kg IV Day
1 and Day 15; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+14 Approximate, Expires: S+365, Routine
BUN
Expected: S+14 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
URINALYSIS, NO MICROSCOPY
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: Urinalysis without Microscopy.
Treatment Parameters
Hold and notify authorizing prescriber for Urine Protein greater than 100 mg/dL or Blood Pressure greater than 160/90
mmHg.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
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Zztestonc,Jeff J [2507481]
8/10/2017 9:42:16 AM Page 21 of 24
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Hypersensitivity reaction to ramucirumab can occur.  For first and second dose, patient should be
treated in a location to optimize emergency care. See Emergency Medications.
Vital Signs
ONCE Starting when released
Obtain Blood Pressure, Heart Rate, Respiratory Rate and Temperature
Patient Instructions(1)
Advise patients to report any bleeding or symptoms of bleeding.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to treatment.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Pre-Medications (delete all that do not apply)
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer prior to chemotherapy. For use in patients who have previously reacted to ramucirumab.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy. For use in patients who have previously reacted to ramucirumab. No more than 4
grams acetaminophen per 24 hours for adults or 15mg/kg per dose for peds <40kg.
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]
8/10/2017 9:42:16 AM Page 22 of 24
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
ramucirumab 648 mg in sodium chloride 0.9 % 250 mL bag
648 mg (8 mg/kg × 81 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer with 0.2 or 0.22 micron filter over 60 minutes. DO NOT dilute with other solutions or co-infuse with other
electrolytes or medications. Hypersensitivity reaction to ramucirumab can occur.  For first and second dose, patient
should be treated in a location to optimize emergency care. See Emergency Medications.
NOTE: Round to nearest 100 mg.
Follow-Up
DAY 15 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: ramucirumab infusion for 90 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Creatinine, BUN, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Urinalysis without microscopy; CHEMOTHERAPY ROOM
APPOINTMENT: ramucirumab for 90 minutes.
Day 15, Cycle 6 –  Planned for 1/11/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Gastric and Gastro-esophageal Junction Adenocarcinoma (Advanced); THERAPY: ramucirumab 8 mg/kg IV Day
1 and Day 15; CYCLE LENGTH: 28 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Treatment Parameters
Hold and notify authorizing prescriber for Blood Pressure greater than 160/90 mmHg.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to ramucirumab can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Vital Signs
ONCE Starting when released
Obtain Blood Pressure, Heart Rate, Respiratory Rate and Temperature
Patient Instructions(1)
Advise patients to report any bleeding or symptoms of bleeding.
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.
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Zztestonc,Jeff J [2507481]
8/10/2017 9:42:16 AM Page 23 of 24
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Administer 30 minutes PRIOR to treatment.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Pre-Medications (delete all that do not apply)
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer prior to chemotherapy. For use in patients who have previously reacted to ramucirumab.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy. For use in patients who have previously reacted to ramucirumab. No more than 4
grams acetaminophen per 24 hours for adults or 15mg/kg per dose for peds <40kg.
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
ramucirumab 648 mg in sodium chloride 0.9 % 250 mL bag
648 mg (8 mg/kg × 81 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer with 0.2 or 0.22 micron filter over 60 minutes. DO NOT dilute with other solutions or co-infuse with other
electrolytes or medications. Hypersensitivity reaction to ramucirumab can occur.  For first and second dose, patient
should be treated in a location to optimize emergency care. See Emergency Medications.
NOTE: Round to nearest 100 mg.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,Jeff J [2507481]
8/10/2017 9:42:16 AM Page 24 of 24
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org