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

/clinical/cckm-tools/content/ppo/name-99113-en.cckm

201608217

page

100

UWHC,UWMF,

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

Breast Paclitaxel(21D:1,8,15) (5640 VER: 4-15-15)

Breast Paclitaxel(21D:1,8,15) (5640 VER: 4-15-15) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


Final Approved VER: 9-10-15 (5640 VER: 4-15-15) Page 1 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org

Title: Paclitaxel
Disease Group: Breast
Disease: Breast Cancer (Adjuvant/Advanced)

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

Cycle Length: 21 days Course: 4 cycles

Note: This regimen follows treatment with cyclophosphamide/doxorubicin

Reference(s): Citron ML, et al. J Clin Oncol 2003;21:1431-39; Perez EA, et al. J Clin Oncol 2001;19:4216-23
Nabholtz JM, et al. J Clin Oncol 1996:14:1858-67; Sparano JA, et al. N Engl J Med 2008;358(16):1663-71

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, Creatinine, Calcium, Total Bilirubin, AST, Alkaline Phosphatase
 Other:


• Day 8 and 15: Obtain CBC without DIFF, ANC
 Other:


Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Day 1: Verify the following labs have been obtained: CBC, ANC, Creatinine, Total Bilirubin, AST
• Day 8 and 15: Verify the following labs have been obtained: CBC, ANC
• Hold and notify provider for:
 Day 1: ANC ≤ 1000/µL or Platelets < 100K/µL or Creatinine > 1.5 X ULN or Total Bilirubin ≥ 1.25 X ULN or
AST ≥ 5 X ULN
 Day 8 and 15: ANC ≤ 1000/µL or Platelets ≤ 75K/µL
• Verify that patient has taken home dexamethasone and document.

Nursing Procedure, Assessment and Monitoring:
• Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion
complete for the first and second dose of PACLItaxel administration. 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





Final Approved VER: 9-10-15 (5640 VER: 4-15-15) Page 2 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org


Premedications/Antiemetics
Give prior to PACLItaxel:
• Diphenhydramine (Benadryl) 50 mg IV once.
• Ranitidine (Zantac) 50 mg IV once.
• Dexamethasone (Decadron) 20 mg IV once PRN. For use only in patients who did not take dexamethasone at
home.


Treatment Medications for Day 1:
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:


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

Treatment Medications for Day 8:
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:


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

Treatment Medications for Day 15:
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:


• PACLItaxel (Taxol) __________mg (80 mg/m2) in non-PVC Bag IV once through non-PVC tubing and
standard in-line filter. Administer over 60 minutes.
Hypersensitivity risk. 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: 9-10-15 (5640 VER: 4-15-15) 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: 3
Take 3 tablets (12 mg) by mouth 12 & 6 hours prior to 2
nd
PACLItaxel dose and 2 tabs (8 mg) 12 & 6 hours
prior to remaining PACLItaxel doses.


 Other:



Follow Up
• Chemotherapy: Day 1, 8 and 15 every 21 days

• Labs: Day 1, 8 and 15 every 21 days
 Other:

• Procedures/Imaging/Scans:








• Other Orders:







MD Signature_________________________________________ Pager______________
Date __________________Time___________________


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