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Breast Paclitaxel Protein Bound(28D:1,8,15) (556 VER: 10-03-16)

Breast Paclitaxel Protein Bound(28D:1,8,15) (556 VER: 10-03-16) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


VER: 9-7-17 (556 VER: 10-03-16) Page 1 of 3
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Paclitaxel Protein Bound Particles (Abraxane)
Disease Group: Breast
Disease: Breast Cancer (Advanced)

Therapy: PACLItaxel Protein Bound Particles 100 to 120 mg/m2 IV Day 1, 8 and 15

Cycle Length: 28 days Course: until disease progression

Reference(s): O’Shaughnessy J, et al. Proc San Antonio Breast Cancer Symposium 2003;14:AB#44.

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, Calcium, Total Bilirubin, AST, Alkaline Phosphatase
 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:
 Day 1: CBC, ANC, Creatinine, AST, Total Bilirubin
 Day 8 and 15: CBC, ANC
• Hold and notify provider for:
 Day 1 and 15: ANC ≤ 1000/µL or Platelets < 100K/µL or Creatinine > 1.5 X ULN or Total Bilirubin ≥ 1.25 X
ULN or AST ≥ 5 X ULN
 Day 8 and 15: 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

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.
 Other:








VER: 9-7-17 (556 VER: 10-03-16) Page 2 of 3
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Treatment Medications for Day 1:
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:


• PACLItaxel protein-bound (Abraxane) __________mg (______mg/m2, range 100 to 120 mg/m2) IV once over
30 minutes.


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


• PACLItaxel protein-bound (Abraxane) __________mg (______mg/m2, range 100 to 120 mg/m2) IV once over
30 minutes.


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


• PACLItaxel protein-bound (Abraxane) __________mg (______mg/m2, range 100 to 120 mg/m2) IV once over
30 minutes.




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















VER: 9-7-17 (556 VER: 10-03-16) Page 3 of 3
Copyright © 2017 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 1 tablet (8 mg) by mouth every 8 hours as needed for nausea/vomiting.

 Other:






Follow Up
• Chemotherapy: Day 1, 8 and 15 every 28 days

• Labs:
 Day 8 and 15 – Obtain CBC, ANC (DIFF if 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 #: ________