Download taxol / cisplatin orders

Form #2398 (2/10)
AUTHORIZATION IS GRANTED TO DISPENSE AND ADMINISTER AN ALTERNATE DRUG PRODUCT ACCEPTABLE TO THE MEDICAL
STAFF'S PHARMACY COMMITTEE UNLESS THE DRUG PRODUCT IS SPECIFICALLY CIRCLED.
1. Admit to:
U C4
U Outpatient Infusion Clinic
Weight _____ Height ______
Body surface _____m2
2. Diagnosis:____________________________________________________________________________________
3. Allergies/Sensitivities (include types of reactions):_____________________________________________________
4. Condition:____________________
5. Diet:______________________________
6. Activity: Ad Lib
7. Vital signs: Baseline, every 15 minutes during 1st hour of paclitaxel (Taxol) infusion, then every 1 hour for next 3
hours, then every 4 hours until paclitaxel (Taxol) complete. Then every shift.
Notify physician of any chest pain, hypotension (SBP less than 90), arrhythmias, bradycardia (HR less than
40/minute).
8. Labs: IV team to draw Comprehensive Metabolic Profile, CBC with Differential, Platelet Count, and Magnesium.
9. Other labs:___________________________________________________________________________________
10. Assure patient has taken oral dexamethasone (20 mg) approximately 12 hours and 6 hours pre paclitaxel (Taxol)
administration. RN______.
11. IV: 1000 mL 0.9% Sodium Chloride + potassium chloride 20 mEq/L + Magnesium Sulfate 16 mEq (2 gram) at 150
ml/hour. When cisplatin complete, increase IV rate to 250 ml/hour for 2 hours, then D/C.
NOTE: HOLD CHEMOTHERAPY & CALL PHYSICIAN IF CREAT GREATER THAN OR EQUAL TO _____, ANC
LESS THAN OR EQUAL TO _____, OR PLATELETS LESS THAN OR EQUAL TO ____.
PACLITAXEL (TAXOL) SHOULD PRECEDE CISPLATIN AS ORDERED.
12. Premedication: Diphenhydramine (Benadryl) 50 mg IVP X 1 dose, famotidine (Pepcid) 20 mg IVP X 1 (or equivalent
dose of current formulary H2 receptor antagonist). Administer 30-60 minutes prior to start of paclitaxel (Taxol).
13. Antiemetics:
អ Ondansetron (Zofran) 24 mg PO (or formulary serotonin antagonist) x 1 dose on day 1
អ Aprepitant (Emend) 125 mg PO on day 1, then 80 mg PO in morning on days 2 & 3
អ Dexamethasone (Decadron) ________ mg PO (12 mg with aprepitant [Emend] or 20 mg without) x 1 dose on
day 1 if not taken at home
អ If using aprepitant (Emend) give dexamethasone (Decadron) 8 mg PO BID with meals on days 2, 3, 4. Start in
morning on day 2.
14. Paclitaxel (Taxol) (________mg/m2) = ______mg IVPB in 0.9% Sodium Chloride - PVC-free bag (or D5W or 0.9%
Sodium Chloride in glass if PVC-free bag unavailable) continuous infusion over ________ hours X 1 dose.
(NOTE: Use PVC-free tubing and 0.22 micron in-line filter.)
15. When paclitaxel (Taxol) ends, give Mannitol 20% 100 ml IVPB over 15 minutes x 1 dose.
16. Cisplatin (________ mg/m2) = ________ mg in 250 ml (total volume) 0.9% Sodium Chloride IVPB over 1 hour x 1
dose. Start when urine output greater than or equal to 100 ml/hr.
17. Furosemide (Lasix) ________mg IVP x 1 prn dyspnea or if urine output falls to less than 100 ml/hour for up to 6
hours after Cisplatin starts.
18. Prochlorperazine (Compazine) 10 mg IV/PO Q6 hours prn nausea/vomiting.
19. Diphenhydramine (Benadryl) 25 mg IVP Q1 hour prn nausea/vomiting unrelieved by prochlorperazine (Compazine).
20. Labs in A.M.:_________________________________________________________________________________
Patient ID Label
The physician's full signature, date & time is to follow the order Abbreviations for names are not acceptable.
Signature
TAXOL / CISPLATIN ORDERS
Date
Time