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GYN Concurrent XRT Cisplatin(21D1,8,15) (5804 VER: 7-14-15 INT)

GYN Concurrent XRT Cisplatin(21D1,8,15) (5804 VER: 7-14-15 INT) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


Final Approved: 07-16-15 (5804 VER: 7-14-15 INT) Page 1 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Cisplatin with Concurrent XRT
Disease Group: Gynecology/Oncology
Disease: Cervical, Vulvar, Vaginal Cancer (Neo-adjuvant/Local/Adjuvant/Advanced)

Therapy: CISplatin 40 mg/m2 IV (maximum dose = 70 mg) on Days 1, 8 and 15 concurrent with radiation

Cycle Length: 21 days Course: Until XRT complete

Reference(s): Lanciano R, et al. J Clin Oncol 2005;23(33):8289-95.

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, 8 and 15: Obtain CBC without DIFF, ANC, Potassium, Magnesium, Creatinine
 Other:


Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Day 1, 8 and 15: Verify the following labs have been obtained: CBC, ANC, Creatinine
• Hold and notify provider for:
 Day 1, 8 and 15: ANC ≤ 500/µL or Platelets ≤ 50K/µL or Hemoglobin < 9 mg/dL or Creatinine > ULN

Nursing Procedure, Assessment and Monitoring:
• Monitor urine output and IV intake.
• Flush/Line Care per Institution standards

Hydration/Fluids:
• sodium chloride 0.9% with potassium chloride 20 mEq IV administer 1000 mL throughout chemotherapy
• sodium chloride 0.9% with potassium chloride 10 mEq IV administer 500 mL following chemotherapy

Premedications/Antiemetics
Give prior to chemotherapy (*indicates preferred antiemetic regimen):
 fosaprepitant (Emend) 150 mg IV once.
 *aprepitant (Emend) 125 mg by mouth once.
 *ondansetron (Zofran) 24 mg by mouth once. PO preferred – may give 12 mg IV if unable to tolerate PO.
 *dexamethasone (Decadron) 4 mg by mouth once. PO preferred – may give 4 mg IV if unable to tolerate PO.
 palonosetron (Aloxi) 0.25 mg IV once.
 Other:







Final Approved: 07-16-15 (5804 VER: 7-14-15 INT) 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:


• CISplatin (Platinol) __________mg (40 mg/m2) IV once over 60 to 90 minutes. Maximum dose: 70 mg.

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:


• CISplatin (Platinol) __________mg (40 mg/m2) IV once over 60 to 90 minutes. Maximum dose: 70 mg.

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:


• CISplatin (Platinol) __________mg (40 mg/m2) IV once over 60 to 90 minutes. Maximum dose: 70 mg.


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





Take Home Medications - (Prescribe Cycle 1, Day 1: Review for adequate supply during treatment)
• dexamethasone (Decadron) 2 mg tablet, Disp. #12, Refills: 0
Take 1 tablet (2 mg) by mouth once daily for 2 days 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 daily for two days following chemotherapy.
(Prescribe only if patient received aprepitant as a premedication)

 Other:







Final Approved: 07-16-15 (5804 VER: 7-14-15 INT) Page 3 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Follow Up
• Chemotherapy: Day 1, 8 and 15 every 21 days

• Labs:
 Day 8 and 15 – Obtain CBC, ANC (DIFF if done locally), Potassium, Magnesium, Creatinine
 Other:





• Radiology: Day 1, 8 and 15 every 21 days. Prior to discharge, confirm XRT scheduled (if applicable).









• Procedures/Imaging/Scans:








• Other Orders:







MD Signature_________________________________________ Pager______________
Date __________________Time___________________


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