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Breast Vinorelbine (567 VER: 2-18-15)

Breast Vinorelbine (567 VER: 2-18-15) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders








VER: 8-12-16 (567 VER: 2-18-15) Page 1 of 2
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org

Title: Vinorelbine
Disease Group: Breast
Disease: Breast Cancer (Advanced)


Therapy: vinorelbine 25 to 30 mg/m2 IV Days 1 and 8

Cycle Length: 21 days Course: 6 cycles

Reference(s): Papaldo P, et al. Ann Oncol 2006;17:630-6.

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


Cycle _______ Starting with:  Day 1 (date) ___________  Day 8 (date) ___________

Pre labs:
• Day 1: Obtain CBC without DIFF, ANC, Creatinine, Calcium, Total Bilirubin, AST, Alkaline Phosphatase
 Other:

• Day 8: Obtain CBC without DIFF, ANC
 Other:

Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Verify the following labs have been obtained:
 Day 1: CBC, ANC, Total Bilirubin, AST
 Day 8: CBC, ANC
• Hold and notify authorizing provider for:
 Day 1: ANC ≤ 1000/µL or Platelets ≤ 100K/µL or Total Bilirubin ≥ 1.5 X upper limits of normal or AST ≥ 5
X upper limits of normal
 Day 8: ANC ≤ 1000/µL or Platelets ≤ 100K/µL

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

Hydration/Fluids:
• sodium chloride 0.9% IV to establish line and for flushing
• sodium chloride 0.9% IV administer 500 mL after vinorelbine when administered through a peripheral IV to
prevent phlebitis

Premedications/Antiemetics: None

Treatment Medications for Day 1: (in order of administration)
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:

• vinorelbine (Navelbine) __________ mg (Dosed at _______ mg/m2 (25 to 30 mg/m2)) IV once via side arm
push. vinorelbine should be followed by sodium chloride 0.9% 500 mL IV when administered through a
peripheral IV to prevent phlebitis.


Treatment Medications (continued on next page)







VER: 8-12-16 (567 VER: 2-18-15) Page 2 of 2
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org




Treatment Medications for Day 8: (in order of administration)
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:

• vinorelbine (Navelbine) __________ mg (Dosed at _______ mg/m2 (25 to 30 mg/m2)) IV once via side arm
push. vinorelbine should be followed by sodium chloride 0.9% 500 mL IV when administered through a
peripheral IV to prevent phlebitis.

Other Orders for Day 1 and/or 8:



Take Home Medications - (Prescribe Cycle 1, Day 1: Review for adequate supply during treatment)
• ondansetron (Zofran) 8 mg tablet, Disp. #30, Refills: 5
Take 1 tablet (8 mg) by mouth every 8 hours as needed for nausea/vomiting.

 Other:



Follow Up
• Chemotherapy: Day 1 and 8 every 21 days

• Labs: CBC without DIFF
 Other:



• Procedures/Imaging/Scans:






• Other Orders:




MD Signature_____________________________ Pager______________
Date _____________Time______________

Order Verification:
RN Signature: _________________ Date: _______ Time: ______ Pager #: ________
RPh Signature: ________________ Date: _______ Time: ______ Pager #: ________