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Head-Neck Concurrent XRT Cisplatin(21D:1,8,15) (979 VER: 10-3-16)

Head-Neck Concurrent XRT Cisplatin(21D:1,8,15) (979 VER: 10-3-16) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


VER: 12-28-16 (979 VER: 10-3-16) Page 1 of 3
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Cisplatin with Concurrent XRT
Disease Group: Head and Neck
Disease: Head and Neck Cancer (Adjuvant/Advanced)

Therapy: CISplatin 40 mg/m
2
IV weekly on Days 1, 8, and 15 of each cycle concurrent with radiotherapy for 5 to
7 weeks until the end of XRT

Cycle Length: 21 days Course: 2 cycles (or until the end of radiotherapy)

References: Bernier J, et al. N Engl J Med 2004;350:1945-52; Adelstein DJ, et al. J Clin Oncol 2003;21:92-8,
Forastiere AA, et al. N Engl J Med 2003;349(22):2091-8, Medina JA, et al. Radiother Oncol 2006;79:34-8,
Beckmann GK, et al. Head Neck 2005;27:36-43.

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, 8 and 15: Obtain CBC without DIFF, ANC, Electrolytes, BUN, Creatinine, Calcium, Albumin, Total
Bilirubin, AST, Alkaline Phosphatase, Magnesium, Glucose
 Other:


Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Day 1, 8, and 15: Verify the following labs have been obtained: CBC, ANC, Creatinine
• Day 1, 8, an 15: Hold and notify MD for: ANC ≤ 1,500/µL or Platelets ≤ 100K/µL or Creatinine > ULN

Nursing Procedure, Assessment and Monitoring:
• Monitor urine output and IV intake. If IV intake is > 2000 mL and urine output is < 500 mL, give furosemide
(See Conditional Medication orders section)

Hydration/Fluids:
• sodium chloride 0.9% IV administer 1000 mL throughout treatment with cisplatin
 Additional additives required- these may be added to any appropriate fluid throughout treatment
 Magnesium _______grams
 Potassium Chloride _________mEq


VER: 12-28-16 (979 VER: 10-3-16) Page 2 of 3
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Premedications/Antiemetics: (May substitute formulary equivalent)
Give prior to chemotherapy (*indicates preferred antiemetic regimen):
 *ondansetron (Zofran) 16 mg by mouth once. PO preferred – may give 8 mg IV if unable to tolerate PO.
 *dexamethasone (Decadron) 8 mg by mouth once. PO preferred – may give 8 mg IV if unable to tolerate PO.
 *aprepitant (Emend) 125 mg by mouth once.
 fosaprepitant (Emend) 150 mg IV once.
 palonosetron (Aloxi) 0.25 mg IV once.
 Other:



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:



• CISplatin (Platinol) _______mg (40 mg/m2) IV once. Administer over 60 to 90 minutes.


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:



• CISplatin (Platinol) _______mg (40 mg/m2) IV once. Administer over 60 to 90 minutes.


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:



• CISplatin (Platinol) _______mg (40 mg/m2) IV once. Administer over 60 to 90 minutes.


Conditional Orders Day 1, 8 and 15:
• Furosemide (Lasix) 20 mg IV once PRN. Administer if IV intake is > 2000 mL and urine output is < 500 mL


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





VER: 12-28-16 (979 VER: 10-3-16) Page 3 of 3
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Take Home Medications
• ondansetron (Zofran) 8 mg tablet Disp #20, Refills: 5
Take 1 tablet (8 mg) by mouth every 8 hours as needed for nausea/vomiting

• prochlorperazine (Compazine) 10 mg tab, Disp #30, Refills: 5
Take 1 tablet (10 mg) by mouth every 6 hours as needed for nausea/vomiting

 aprepitant (Emend) 80 mg capsule, Disp #2, Refills: 5
Take 1 capsule (80 mg) by mouth once daily for 2 days following chemotherapy
(Prescribe only if patient received aprepitant as a premedication)

 Other:


Follow Up
• Chemotherapy: Day 1, 8 and 15 every 21 days for two cycles

• Labs:
 Other:



• Procedures/Imaging/Scans:










• Other Orders:









MD Signature_________________________________________ Pager______________
Date __________________Time___________________

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