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Gyn Gemcitabine 28D:1,8,15) (500 VER: 08-19-13)

Gyn Gemcitabine 28D:1,8,15) (500 VER: 08-19-13) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


VER: 09-22-16 (500 VER: 08-19-13) Page 1 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Gemcitabine
Disease Group: Gynecology/Oncology
Disease: Ovarian Cancer, Primary Peritoneal, Fallopian Tube (Advanced), Cervical, Vulvar, Vaginal (Advanced),
Uterine Sarcoma (Advanced)

Therapy: gemcitabine 1000 mg/m2 IV Days 1, 8, and 15

Cycle Length: 28 days Course: Until disease progression

Reference(s): Rose PG, et al. Int J Gynecol Cancer 2005;15:18-22; Lund B, et al. J Natl Cancer Inst
1994;86:1530-33; Look KY, et al. Gynecol Oncol 2004; 92:644-47.

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


Cycle _____ Starting with:  Day 1 (date) __________  Day 8 (date) _________  Day 15 (date) _________

Pre labs:
• Day 1: Obtain CBC without DIFF, ANC, Creatinine, AST, Total Bilirubin, CA 125 (for ovarian, fallopian tube, and
primary peritoneal cancer)
 Other:


• Day 8 and 15: Obtain CBC without DIFF, ANC
 Other:


Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Verify the following labs have been obtained: CBC, ANC
• Hold and notify authorizing provider for:
 Day 1: ANC ≤ 1000/µL or Platelets ≤ 75K/µL or Creatinine > ULN
 Day 8 and 15: ANC ≤ 1000/µL or Platelets ≤ 75K/µL

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

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

Premedications/Antiemetics: (May substitute formulary equivalent)

Give prior to chemotherapy (*indicates preferred antiemetic regimen):
 *ondansetron (Zofran) 8 mg by mouth once. PO preferred – may give 8 mg IV if unable to tolerate PO.
 *dexamethasone (Decadron) tab 10 mg by mouth once. PO preferred – may give 10 mg IV if unable to tolerate
PO.
 Other:



VER: 09-22-16 (500 VER: 08-19-13) Page 2 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
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:



• gemcitabine __________ mg (1000 mg/m²) IV once 30 minutes. Additional sodium chloride 0.9% IV may be y-
set into IV site to decrease site irritation.


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:



• gemcitabine __________ mg (1000 mg/m²) IV once 30 minutes. Additional sodium chloride 0.9% IV may be y-
set into IV site to decrease site irritation.


Treatment Medications for Day 15: (in order of administration)
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:



• gemcitabine __________ mg (1000 mg/m²) IV once 30 minutes. Additional sodium chloride 0.9% IV may be y-
set into IV site to decrease site irritation.



Other Orders for Day 1 and/or Day 8 and/or Day 15:





VER: 09-22-16 (500 VER: 08-19-13) Page 3 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Take Home Medications - (Prescribe Cycle 1, Day 1: Review for adequate supply during treatment)
• ondansetron (Zofran) 8 mg tablet Disp. #30, Refills: 5
Take 8 mg (1 tablet) by mouth every 8 hours as needed for nausea/vomiting

 Other:




Follow Up
 Chemotherapy: Day 1, Day 8 and Day 15 every 28 Days

 Labs:
• Day 22 – Obtain CBC without DIFF, ANC (DIFF if to be done locally)
 Other:


• Procedures/Imaging/Scans:












• Other Orders:










MD Signature__________________________________ Pager______________

Date ________________Time______________

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