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GI Capecitabine 1000 MG (21D1-14) (426 VER: 04-19-13)

GI Capecitabine 1000 MG (21D1-14) (426 VER: 04-19-13) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


Final Approved VER: 05-11-16 (426 VER: 04-19-13) Page 1 of 2
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Capecitabine
Disease Group: Gastrointestinal
Disease: Hepatocellular (Advanced), Cholangiocarcinoma (Advanced), Gall Bladder Cancer (Advanced)

Therapy: capecitabine 1000 mg/m2 by mouth twice daily Day 1 through 14

Cycle Length: 21 days Course: 8 cycles

Reference(s): Patt Y, et al. Cancer 2004;100(3):578-86.

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


Cycle _______ Starting with:  Day 1 (date) ___________

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



Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Verify the following labs have been obtained: WBC, ANC, Platelets, Creatinine
• Hold and notify provider for: ANC ≤ 1000/µL or Platelets ≤ 75K/µL or Creatinine > ULN
• Cycle 2+: Verify that patient has taken capecitabine and document.

Nursing Procedure, Assessment and Monitoring:
• Educate/reinforce with patient regarding hand and foot syndrome with capecitabine and to call with concerns.
• Flush/Line Care per Institution standards

Hydration/Fluids: None

Premedications/Antiemetics: – None

Treatment Medications for Day 1:
• capecitabine (Xeloda) – refer to Take Home Medications section


Other Orders for Day 1:







Final Approved VER: 05-11-16 (426 VER: 04-19-13) Page 2 of 2
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)
• capecitabine (Xeloda) 1000 mg/m2 by mouth 2 times daily for 14 days. (Round dose to available tablet sizes
of 500 mg and 150 mg.)

Take _______ mg in AM and ________ mg in PM daily beginning evening of ____________ (date) through
morning of ____________ (date).

• 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
• Clinic Visit: Day 1 every 21 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 #: ________