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Lung Cisplatin(21D1)_Gemcitabine(21D1_8) (341 VER: 2-14-13)

Lung Cisplatin(21D1)_Gemcitabine(21D1_8) (341 VER: 2-14-13) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders





Final Approved: 12-23-14 (341 VER: 2-14-13) Page 1 of 4
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Cisplatin/Gemcitabine
Disease Group: Lung
Disease: Non-Small Cell Lung Cancer (Adjuvant/Advanced)

Reference(s): Sandler AB, et al. J Clin Oncol 2000;18:122-30


Therapy: Gemcitabine 1000 mg/m2 IV Day 1 and 8, Cisplatin 75 mg/m2 IV Day 1
Cycle Length: 21 days
Course: 4 to 6 cycles


Informed consent obtained:  Yes  No

Allergies: _______________________________________________

Height _________cm Weight __________kg BSA ________m
2


Cycle _______, Day 1 Date ____________

Pre labs:
• CBC without DIFF, ANC, Electrolytes, BUN, Creatinine, Calcium, Albumin, Total Bilirubin, AST,
Alkaline Phosphatase, Magnesium

Labs obtained on (date): ___________  Local  Non-Local lab

Lab Results:
WBC ____________ K/µL ANC _____________/µL Platelets ____________ K/µL
Creatinine ________ mg/dL


Treatment Conditions:
• Verify the following labs have been obtained: WBC, ANC, Platelets, Creatinine
• Hold and notify authorizing provider for: ANC less than 1000/µL or Platelets less than 100K/µL

Nursing Procedure, Assessment and Monitoring:
• Measure IV intake and urine output. If IV intake is greater than 2000 mL and urine output is less
than 500 mL, give Furosemide. See Conditional Orders section.
• Flush/Line Care per Institution standards







Final Approved: 12-23-14 (341 VER: 2-14-13) Page 2 of 4
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Hydration:
• Sodium Chloride 0.9% IV administer 1000 mL throughout chemotherapy
 Additional additives required - these may be added to any appropriate fluid throughout
treatment
 Magnesium _______ grams
 Potassium Chloride __________ mEq

Pre Medications:
• Fosaprepitant (Emend) 150 mg IV once. Give prior to chemotherapy.
• Ondansetron (Zofran) tablet 24 mg by mouth once. Give prior to chemotherapy.
• Dexamethasone (Decadron) tablet 12 mg by mouth once. Give prior to chemotherapy.

Emergency Medications: none

Treatment Medications: (in order of administration)

• Gemcitabine (Gemzar) ___________ mg (1000 mg/m2) IV once. Additional sodium chloride
0.9% may be y-set into IV site to decrease site irritation.

• Cisplatin (Platinol) __________ mg (75 mg/m2) IV once

Conditional Orders:
• Furosemide (Lasix) 20 mg IV once PRN. Administer if IV intake is greater than 2000 mL and
urine output less than 500 mL

Other Orders:








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








Final Approved: 12-23-14 (341 VER: 2-14-13) Page 3 of 4
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Cycle _______, Day 8 Date ____________

Pre labs:
• CBC without DIFF, ANC

Labs obtained on (date): ___________  Local  Non-Local lab

Lab Results:  NA
WBC ____________ K/µL ANC _____________/µL Platelets ____________ K/µL

Treatment Conditions:
• Verify the following labs have been obtained: WBC, ANC, Platelets

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

Hydration:
• Sodium Chloride 0.9% IV to establish line and for flushing

Pre Medications:
• Ondansetron (Zofran) 8 mg by mouth once. Give prior to chemotherapy.

Emergency Medications: none

Treatment Medications: (in order of administration)
• Gemcitabine (Gemzar) ___________ mg (1000 mg/m2) IV once. Additional sodium chloride
0.9% may be y-set into IV site to decrease site irritation.

Other Orders:






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





Final Approved: 12-23-14 (341 VER: 2-14-13) Page 4 of 4
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Take Home Medications
• Dexamethasone (Decadron) 4 mg tablet, Disp. #24 tablets, Refills: 5
Take 2 tablets (8 mg) by mouth one time daily for 3 days following chemotherapy.

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

• Other:





Follow Up
• Interim Labs needed:  No  Yes – Day 15 ___________ (Date)

Labs: CBC, ANC (DIFF if to be done locally)

Other:

• Return to Clinic on Day 8 ___________ (Date)

Labs: CBC, ANC (DIFF if to be done locally)

Other:

Chemotherapy Appointment: Gemcitabine for 90 minutes.

• Return to Clinic on Day 22 (Day 1 of next cycle) ___________________ (Date) for appointment
with Dr. _________________

Labs: CBC, ANC (DIFF if to be done locally), Electrolytes, BUN, Creatinine, Calcium, Albumin,
Total Bilirubin, AST, Alkaline Phosphatase, Magnesium

Other:

Chemotherapy Appointment: Gemcitabine and Cisplatin for 180 minutes.

MD Signature_____________________________ Pager______________
Date _____________Time______________