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Breast Trastuzumab (21D1) (Part 2 of 2) (3042 VER: 10-1-15)

Breast Trastuzumab (21D1) (Part 2 of 2) (3042 VER: 10-1-15) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


Final Approved VER: 09-27-16 (3042 VER: 10-1-15) Page 1 of 2
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Trastuzumab
Disease Group: Breast
Disease: Breast Cancer (Adjuvant)

Therapy: trastuzumab 6 mg/kg IV Day 1

Cycle Length: 21 days Course: 11 cycles (for a total of 52 weeks including treatment from previous order set)

Note: This regimen follows treatment with CARBOplatin-DOCEtaxel-trastuzumab

Reference(s): Valero V, et al. J Clin Oncol 2011;29(2):149-56.

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


Cycle _______ Starting with:  Day 1 (date) ___________

Pre labs:
 Other:


Treatment Conditions: Verify Informed consent obtained Day 1 of each cycle.

Nursing Procedure, Assessment and Monitoring: Flush/Line Care per Institution standards

Hydration/Fluids: sodium chloride 0.9% IV to establish line and for flushing

Premedications/Antiemetics: None

Treatment Medications for Day 1:
• trastuzumab (Herceptin) __________mg (6 mg/kg) IV once over 30 minutes.
Hypersensitivity risk. For first and second dose, patient should be treated in a location to optimize emergency
care.

Other Orders for Day 1:






Take Home Medications - (Prescribe Cycle 1, Day 1: Review for adequate supply during treatment)
 Other:





Final Approved VER: 09-27-16 (3042 VER: 10-1-15) Page 2 of 2
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Follow Up
• Chemotherapy: Day 1 every 21 Days

• Labs:
 Other:




• Procedures/Imaging/Scans:


















• Other Orders:









MD Signature_________________________________________ Pager______________
Date __________________Time___________________

Order Verification:
RN Signature: __________________________ Date: ___________ Time: __________ Pager #: ________
RPh Signature: _________________________ Date: ___________ Time: __________ Pager #: ________