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Lung Cisplatin Cyclophosohamide Doxorubicin(21D1) (4345 VER: 03-05-15)

Lung Cisplatin Cyclophosohamide Doxorubicin(21D1) (4345 VER: 03-05-15) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


Final Approved VER: 02-02-16 (4345 VER: 03-05-15) Page 1 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Cisplatin/Cyclophosphamide/Doxorubicin
Disease Group: Lung
Disease: Thymic Malignancies (Adjuvant/Advanced), Salivary Gland (Advanced)

Therapy: doxorubicin 50 mg/m2 IV Day 1,
CISplatin 50 mg/m2 IV Day 1,
cyclophosphamide 500 mg/m2 IV Day 1

Cycle Length: 21 days Course: maximum of 8 cycles

Reference(s): Loehrer PJ, et al. J Clin Oncol 1994;12:1164-8; Laurie SA, et al. Clin Oncol 2006;24(17):2673-8

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m2

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

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



Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Verify the following labs have been obtained: WBC, ANC, Platelets, Electrolytes, Glucose, BUN, Creatinine,
Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Magnesium
• Hold and notify provider for: ANC < 1000/µL or Platelets < 100K/µL or Creatinine > ULN or Total Bilirubin ≥ 1.8
mg/dL

Nursing Procedure, Assessment and Monitoring:
• Instruct patient to drink 8 to 10 (8 oz.) glasses of water day prior to, day of and for two days after treatment.
• If IV intake is > 2000 mL and urine output is < 500 mL, give furosemide. See Conditional Orders section.
• Flush/Line Care per Institution standards

Hydration/Fluids: 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



Final Approved VER: 02-02-16 (4345 VER: 03-05-15) Page 2 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Premedications/Antiemetics: (May substitute formulary equivalent)
Give prior to chemotherapy (*indicates preferred antiemetic regimen):
 *ondansetron (Zofran) 24 mg by mouth once. PO preferred – may give 12 mg IV if unable to tolerate PO.
 *dexamethasone (Decadron) 12 mg by mouth once. PO preferred – may give 10 mg IV if unable to tolerate
PO.
 *aprepitant (Emend) 125 mg by mouth once.
 fosaprepitant (Emend) 150 mg IV 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:



• doxorubicin (Adriamycin) __________mg (50 mg/m2) IV once IV side arm push over 3 to 5 mL/minute into
running IV

• CISplatin (Platinol) ____________ mg (50 mg/m2) IV once over 60 to 90 minutes

• cyclophosphamide (Cytoxan) __________ mg (500 mg/m2) IV once over 30 to 60 minutes


Conditional Orders Day 1:
• furosemide (Lasix) 20 mg IV once PRN. Administer if intake is > 2000 mL and urine output < 500 mL.

Other Orders for Day 1:






Take Home Medications - (Prescribe Cycle 1, Day 1: Review for adequate supply during treatment)
• dexamethasone (Decadron) 4 mg tablet, Disp. #24, Refills: 7
Take 2 tablets (8 mg) by mouth once daily for 3 days following chemotherapy.

• ondansetron (Zofran) 8 mg tablet, Disp. #30, Refills: 7
Take 1 tablet (8 mg) by mouth every 8 hours as needed for nausea/vomiting.

 aprepitant (Emend) 80 mg capsule, Disp. #2, Refills: 7
Take 1 capsule by mouth once daily for two days following chemotherapy.
(Prescribe only if patient received aprepitant as a premedication)

 Other:





Final Approved VER: 02-02-16 (4345 VER: 03-05-15) Page 3 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Follow Up
• Chemotherapy: Day 1 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 #: ________