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Head-Neck Cisplatin(28D1)/Fluorouracil(28D1-4) Post XRT (5799 VER: 07-23-15)

Head-Neck Cisplatin(28D1)/Fluorouracil(28D1-4) Post XRT (5799 VER: 07-23-15) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


Final Approved VER: 12-23-15 (5799 VER: 07-23-15) Page 1 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Cisplatin/Fluorouracil post XRT
Disease Group: Head and Neck
Disease: Nasopharyngeal Cancer (Adjuvant/Advanced)

Therapy: Begin after radiotherapy
CISplatin 80 mg/m2 IV Day 1,
fluorouracil 4000 mg/m2 IV administered as continuous infusion IV over 96 hours
(Total dose = 4000 mg/m2 IV over 96 hours per home infusion) on Day 1 through 4.

Cycle Length: 28 days Course: 3 cycles

Reference(s): Al-Sarraf M, et al. J Clin Oncol 1998;16(4):1310-17; Chan AT, et al. J Clin Oncol 2002;20(8):2038-44;
Jagdis A, et al. Am J Clin Oncol 2014;37(1):63-69

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


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

Pre labs:
• Day 1: Obtain CBC with DIFF, Electrolytes, Creatinine, BUN, Calcium, Albumin, Total Bilirubin, AST, Alkaline
Phosphatase, Magnesium, Glucose
 Other:


Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Day 1: Verify the following labs have been obtained: CBC with DIFF, Creatinine
• Day 1: Hold and notify provider for: ANC < 1500/µL or Platelets < 100K/µL or Creatinine > ULN

Nursing Procedure, Assessment and Monitoring:
• Monitor urine output and IV intake.
• Educate/reinforce with patient about hand-foot syndrome and mucositis that occurs with fluorouracil.
• Flush/Line Care per Institution standards
• Disconnect pump upon completion of 96-hour fluorouracil infusion on Day 5.
 In Clinic  At Home By Patient  At Home by Home Health Nurse  Other _______________

Hydration/Fluids:
• sodium chloride 0.9% IV administer 1000 mL over 1 to 2 hours prior to CISplatin.
• sodium chloride 0.9% IV administer 500 mL for post-CISplatin hydration if needed.
 Additional additives required – these may be added to any appropriate fluid throughout treatment
 Magnesium ______ grams
 Potassium chloride ______ mEq







Final Approved VER: 12-23-15 (5799 VER: 07-23-15) Page 2 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Premedications/Antiemetics
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.
 fosaprepitant (Emend) 150 mg IV once.
 *aprepitant (Emend) 125 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 (Platinol) __________mg (80 mg/m2) IV once over 60 to 90 minutes.


• fluorouracil (Adrucil) ____________ mg (4000 mg/m2) continuous IV infusion over 96 hours


Conditional Orders Day 1:
• furosemide (Lasix) 20 mg IV once PRN. Administer if intake is greater than 2000 mL and urine output less
than 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. #18, Refills: 0
Take 2 tablets (8 mg) by mouth once on Days 2, 3, and 4 following chemotherapy.

• 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.

 aprepitant (Emend) 80 mg capsule, Disp. #2, Refills: 5
Take 1 capsule by mouth once on Days 2 and 3 following chemotherapy.
(Prescribe only if patient received aprepitant as a premedication)

 Other:



Final Approved VER: 12-23-15 (5799 VER: 07-23-15) Page 3 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org

Follow Up
• Chemotherapy: Day 1 every 28 days

• Labs: None
 Other:





• Procedures/Imaging/Scans:















• Other Orders:









MD Signature_________________________________________ Pager______________
Date __________________Time___________________


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