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Breast Gemcitabine(28D1_8_15) (559 VER: 02-18-15)

Breast Gemcitabine(28D1_8_15) (559 VER: 02-18-15) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


Final Approved VER: 05-17-16 (559 VER: 02-18-15) Page 1 of 4
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Gemcitabine
Disease Group: Breast
Disease: Breast Cancer (Advanced)

Therapy: gemcitabine 800 to 1200 mg/m2 IV Day 1, 8 and 15

Cycle Length: 28 days Course: until disease progression

Reference(s): Seidman AD, et al. Oncol 2001;15:11-14, Modi S, et al. Clin Breast Cancer 2005;6:55-60.

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
 Other:



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



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



Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Day 1, 8 and 15: Verify the following labs have been obtained: WBC, ANC, Platelets
• Day 1, 8, and 15: Hold and notify provider for: ANC ≤ 1000/µL or Platelets ≤ 75K/µL

Nursing Procedure, Assessment and Monitoring: Flush/Line Care per Institution standards

Hydration/Fluids: sodium chloride 0.9% IV to establish line and for flushing



Final Approved VER: 05-17-16 (559 VER: 02-18-15) Page 2 of 4
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Premedications/Antiemetics: (May substitute formulary equivalent)
Day 1: Give prior to chemotherapy (*indicates preferred antiemetic regimen):
 *ondansetron (Zofran) 8 mg by mouth once. PO preferred – may give 8 mg IV if unable to tolerate PO.
 Other:



Day 8: Give prior to chemotherapy (*indicates preferred antiemetic regimen):
 *ondansetron (Zofran) 8 mg by mouth once. PO preferred – may give 8 mg IV if unable to tolerate PO.
 Other:



Day 15: Give prior to chemotherapy (*indicates preferred antiemetic regimen):
 *ondansetron (Zofran) 8 mg by mouth once. PO preferred – may give 8 mg IV if unable to tolerate PO.
 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:


• gemcitabine (Gemzar) ________mg (________ mg/m2 (range 800 to 1200 mg/m2)) IV once over 30 minutes.
Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.


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:


• gemcitabine (Gemzar) ________mg (________ mg/m2 (range 800 to 1200 mg/m2)) IV once over 30 minutes.
Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.


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:


• gemcitabine (Gemzar) ________mg (________ mg/m2 (range 800 to 1200 mg/m2)) IV once over 30 minutes.
Additional sodium chloride 0.9% may be y-set into IV site to decrease site irritation.

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





Final Approved VER: 05-17-16 (559 VER: 02-18-15) Page 3 of 4
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)
• 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
• Chemotherapy: Day 1, 8 and 15 every 28 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 #: ________


Final Approved VER: 05-17-16 (559 VER: 02-18-15) Page 4 of 4
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org