Sp-orders-q1.qxd

Order Sheet
Protocol Zometa
PRE CHEMO LABS: ______________________________________________________________________________________________________
Hold chemotherapy for: ■ WBC < _________________ ■ Other: _________________________________ Proceed with chemotherapy if: ■ WBC > _________________ PRE HYDRATION ORDERS:
■ D5½NS with 20mEq KCI/L x ____ liters over _____ hours ■ Other: ___________________________________________ Procrit ______ u
■ may hold hydration during chemotherapy infusion POST HYDRATION ORDERS: ■ D5½NS with 20mEq KCI/L x ____ liters over _____ hours
for HCT <36
■ Other: ___________________________________________ ANTIEMETIC REGIMEN
PREMEDICATIONS
■ Decadron ________ mg in 50cc NS IVPB over 15 min.
■ Mannitol 12.5 grams in 50cc NS IVPB over 15 min. prior to Cisplatin Dolasetron mesylate (Anzemet) ______ mg in 50cc NS IVPB over 15 min. ■ Diphenhydramine 25/50 mg. in 50cc NS IVPB over 15 min. prior to Paclitaxel ■ Ondansetron (Zofran) ________ mg in 50cc NS IVPB over 15 min.
■ Cimetidine (Tagamet) 300 mg. in 50cc NS IVPB over 15 min. prior to Paclitaxel ■ Lorazepam (Ativan) ________ mg in 50cc NS IVPB over 15 min.
■ Amifostine (Ethyol) _____ mg. (740 mg/m2) IVP/IVPB prior to chemotherapy, A.S.O* ■ Promethazine HCL (Phenergan) ______ mg in 50cc NS IVPB over 15 min. ■ Furosemide _____ mg. IVP, prior to chemotherapy ________________________________________________ T FOR
■ Other: ________________________________________________ ODUCTION
Drug Name (Generic Name - Do Not Abbreviate) Treatment/Dosage Modification Related to: ■ toxicity ■ change in BSA ■ progression of disease ■ other: _________________________________________ ______________________________________________________________ CENTER FOR CANCER AND BLOOD DISORDERS – CHEMOTHERAPY ORDER FORM
6420 Rockledge Drive ◆ Suite 4100 ◆ Bethesda, Maryland 20817
Name: ________________________________________________ Acct. No.: ________________ Date: ________________ Diagnosis: ___________________________ Protocol: _____________________ ! New/Change ! Repeat Port: ! Yes ! No Height: _________ in. Weight: _________ lbs. BSA: _________ m2 PRE CHEMO LABS: ______________________________________________________________________________________________________
Hold chemotherapy for: ■ WBC < _________________ ■ Other: _________________________________ Proceed with chemotherapy if: ■ WBC > 3,000
■ Platelets > 100,000
■ Standard
PRE HYDRATION ORDERS:
■ D5½NS with 20mEq KCI/L x ____ liters over _____ hours ■ Other: ___________________________________________ ARANESP/Procrit ______
■ may hold hydration during chemotherapy infusion POST HYDRATION ORDERS: ■ D5½NS with 20mEq KCI/L x ____ liters over _____ hours
for Hgb <12
■ Other: ___________________________________________ ANTIEMETIC REGIMEN
PREMEDICATIONS
Decadron ________ mg in 50cc NS IVPB over 15 min.
■ Diphenhydramine 25/50 mg. PO/IV in 50cc NS over 15 min.
■ Dolasetron mesylate (Anzemet) ______ mg in 50cc NS IVPB over 15 min. ■ Cimetidine (Tagamet) 300 mg. in 50cc NS IVPB over 15 min. prior to Paclitaxel ■ Ondansetron (Zofran) ________ mg in 50cc NS IVPB over 15 min.
■ Amifostine (Ethyol) _____ mg. IV/SC prior to chemotherapy/radiation IV over Lorazepam (Ativan) ________ mg in 50cc NS IVPB over 15 min.
Furosemide _____ mg. IVP, prior to chemotherapy ■ Promethazine HCL (Phenergan) ______ mg in 50cc NS IVPB over 15 min. ■ Other: ________________________________________________ ■ Tylenol 650 mg PO _____________.
■ Other: ________________________________________________ ODUCTION
Drug Name (Generic Name - Do Not Abbreviate) GCSF _________mcg SQ QD x _________.
Start:__________________
Treatment/Dosage Modification Related to: ■ toxicity ■ change in BSA ■ progression of disease ■ other: _________________________________________ ______________________________________________________________ Order Sheet
Injection
ODUCTION
Please sign and date the type of injection you want to order for your patient and dose.
______________________________________________________________

Source: http://www.scriptoria-llc.com/services/samples/chemo-orders.pdf