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Lung Paclitaxel(28D:1,8,15) (354 VER: 03-05-15)

Lung Paclitaxel(28D:1,8,15) (354 VER: 03-05-15) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


Final Approved VER: 01-20-16 (354 VER: 03-05-15) Page 1 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Paclitaxel
Disease Group: Lung
Disease: Small Cell Lung Cancer (Advanced)

Therapy: PACLItaxel 80 mg/m2 IV Day 1, 8 and 15

Cycle Length: 28 days Course: 4 to 6 cycles

Reference(s): Yamamoto N, et al. Anticancer Res 2006;26(1B):777-81

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, Electrolytes, BUN, Creatinine, Calcium, Albumin, Total Bilirubin, AST,
Alkaline Phosphatase
 Other:


• Day 8 and15: Obtain CBC without DIFF, ANC
 Other:


Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Day 1, 8 and 15: Verify the following labs have been obtained: WBC, ANC, Platelets
• Day 1, 8 and 15: Hold and notify provider for: ANC < 1000/µL or Platelets < 100K/µL
• Verify that patient has taken home dexamethasone and document.

Nursing Procedure, Assessment and Monitoring:
• Monitor vital signs during PACLItaxel administration every 15 minutes for the first hour and then every 30
minutes until infusion complete for the first and second dose. Monitor vital signs every 30 minutes for all
subsequent doses if previous doses tolerated.
• Flush/Line Care per Institution standards

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

Premedications/Antiemetics
Give prior to paclitaxel:
• dexamethasone (Decadron) 20 mg IV Once PRN. For patients who did not take dexamethasone at home.
• diphenhydramine (Benadryl) 50 mg IV once
• ranitidine (Zantac) 50 mg IV once
 Other:



Final Approved VER: 01-20-16 (354 VER: 03-05-15) 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:


• PACLItaxel (Taxol) __________mg (80 mg/m2) IV once over 60 minutes. Infuse through non-PVC tubing and
0.22 micron in-line non-DEHP (non-PVC) filter.
Hypersensitivity to PACLItaxel can occur. For first and second dose, patient should be treated in a location
to optimize emergency care.


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:


• PACLItaxel (Taxol) __________mg (80 mg/m2) IV once over 60 minutes. Infuse through non-PVC tubing and
0.22 micron in-line non-DEHP (non-PVC) filter.
Hypersensitivity to PACLItaxel can occur. For first and second dose, patient should be treated in a location
to optimize emergency care.


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:


• PACLItaxel (Taxol) __________mg (80 mg/m2) IV once over 60 minutes. Infuse through non-PVC tubing and
0.22 micron in-line non-DEHP (non-PVC) filter.
Hypersensitivity to PACLItaxel can occur. For first and second dose, patient should be treated in a location
to optimize emergency care.



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






Final Approved VER: 01-20-16 (354 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. #50, Refills: 1
Take 3 tablets (12 mg) by mouth 12 and 6 hours prior to second PACLItaxel dose and 2 tablets (8 mg) 12 and
6 hours prior to the remaining PACLItaxel doses.

• 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:
 Other:



• Procedures/Imaging/Scans:











• Other Orders:









MD Signature_________________________________________ Pager______________
Date __________________Time___________________


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