/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/ppo/,

/clinical/cckm-tools/content/ppo/name-99049-en.cckm

201608217

page

100

UWHC,UWMF,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Preprinted Paper Orders

Lung Cisplatin(21D:1)/Etoposide(21D:1-3) (349 VER: 03-05-15)

Lung Cisplatin(21D:1)/Etoposide(21D:1-3) (349 VER: 03-05-15) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


Final Approved VER: 12-09-15 (349 VER: 03-05-15) Page 1 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Cisplatin/Etoposide
Disease Group: Lung
Disease: Small Cell Lung Cancer (Adjuvant/Advanced), Thymic Malignancy (Neoadjuvant/Adjuvant/Advanced)

Therapy: CISplatin 60 mg/m2 IV Day 1
etoposide 120 mg/m2 IV Days 1, 2, and 3

Cycle Length: 21 days Course: Small Cell Lung Cancer - 4 cycles, Thymic Malignancy - 8 cycles

Reference(s): Sundstrom S, et al. J Clin Oncol 2002; 20:4665-72, Giaccone G, et al. J Clin Oncol 1996; 14:814-
20

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


Cycle _______ Starting with:  Day 1 (date) _________  Day 2 (date) _________  Day 3 (date) ________

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

Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Day 1: Verify the following labs have been obtained: WBC, ANC, Platelets, Creatinine
• Day 1: Hold and notify provider for: ANC < 1000/µL or Platelets < 100K/µL

Nursing Procedure, Assessment and Monitoring:
• Measure urine intake and 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

Hydration/Fluids:
• Day 1: 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

• Day 2 and 3: sodium chloride 0.9% IV to establish line and for flushing

Premedications/Antiemetics
Day 1: Give prior to chemotherapy (*indicates preferred antiemetic regimen):
 *ondansetron (Zofran) 24 mg by mouth once. PO preferred – may give 10 mg IV if unable to tolerate PO.
 *dexamethasone (Decadron) 12 mg by mouth once. PO preferred – may give 12 mg IV if unable to tolerate
PO.
 *fosaprepitant (Emend) 150 mg IV once.
 aprepitant (Emend) 125 mg by mouth once.
 palonosetron (Aloxi) 0.25 mg IV once.
 Other:

Final Approved VER: 12-09-15 (349 VER: 03-05-15) Page 2 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Premedications/Antiemetics (cont.)
Day 2: 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) 8 mg by mouth once. PO preferred – may give 8 mg IV if unable to tolerate PO.
 aprepitant (Emend) 80 mg by mouth once.
 palonosetron (Aloxi) 0.25 mg IV once.
 Other:

Day 3: 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) 8 mg by mouth once. PO preferred – may give 8 mg IV if unable to tolerate PO.
 aprepitant (Emend) 80 mg by mouth 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 (Paraplatin) __________mg (60 mg/m2) IV once over 60 to 90 minutes

• etoposide (Vepesid) ____________ mg (120 mg/m2) IV once over 30 to 60 minutes through non-PVC tubing

Treatment Medications for Day 2: (in order of administration)
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:


• etoposide (Vepsid) ____________ mg (120 mg/m2) IV once over 30 to 60 minutes through non-PVC tubing

Treatment Medications for Day 3: (in order of administration)
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:


• etoposide (Vepsid) ____________ mg (120 mg/m2) IV once over 30 to 60 minutes through non-PVC tubing


Conditional Orders for Day 1:
• furosemide (Lasix) 20 mg IV once PRN. IV push rate 10 mg/minute. Administer if IV intake is greater than
2000 mL and urine output is less than 500 mL.

Other Orders for Day 1, 2 and/or 3:





Final Approved VER: 12-09-15 (349 VER: 03-05-15) 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)
• dexamethasone (Decadron) 4 mg tablet, Disp. #8, Refills: 1
Take 2 tablets (8 mg) by mouth once on Day 4.

• ondansetron (Zofran) 8 mg tablet, Disp. #30, Refills: 5
Take 1 tablet (8 mg) by mouth every 8 hours as needed for nausea/vomiting.

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


 Other:



Follow Up
• Chemotherapy: Day 1, 2 and 3 every 21 days

• Labs:
 Day 10 – 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 #: ________