If this file opens in Compatibility Mode using Microsoft Word, convert to the latest document format to avoid potential formatting issues.	

IP CISPLATIN / PACLITAXEL	

Types:      ONCOLOGY TREATMENT
Synonyms:  SIS, CISPLATIN, PACLITAXEL, TAXOL, PLATINOL, PAX, TACK, GYNECOLOGIC , MALIGNANCY , NSCLC, NON SMALL CELL LUNG CANCER

Cycle 1	Repeat 1 time	Cycle length: 21 days	Day 1	Perform every 1 day x1		Provider Communication
  	ONC PROVIDER COMMUNICATION 64	Interval: Once	Occurrences: --	Comments:	Verify Hep B panel status prior to cycle. Date *** of panel. Result positive/negative/pending/unknown:22867

The required components for the hepatitis B panel includes: Hepatitis B surface antigen (HBsAg), total hepatitis B core antibody (anti-HBc), and hepatitis B antibody (anti-HBs).
			Labs
☑	COMPREHENSIVE METABOLIC PANEL	Interval: Once	Occurrences: --		☑	CBC WITH PLATELET AND DIFFERENTIAL	Interval: Once	Occurrences: --		☑	MAGNESIUM LEVEL	Interval: Once	Occurrences: --		☐	CANCER ANTIGEN 125	Interval: Once	Occurrences: --		☐	LDH	Interval: Once	Occurrences: --		☐	URIC ACID LEVEL	Interval: Once	Occurrences: --			Nursing Orders
  	TREATMENT CONDITIONS 12	Interval: Until discontinued	Occurrences: --	Comments:	HOLD and notify provider if 
o ANC LESS than 1000; 
o Platelets LESS than 100,000; 
o SCr GREATER than 1.5.
			Nursing Orders
  	TREATMENT CONDITIONS 38	Interval: Once	Occurrences: --	Comments:	Hold and contact provider if 
o AST or ALT GREATER than 10x ULN OR
o Total Bilirubin GREATER than 1.25x ULN.
			Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Line Care
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Pre-Hydration
  	sodium chloride 0.9 % infusion 1,000 mL	Dose: 1,000 mL	Route: intravenous	once @ 250 mL/hr for 1 dose				Instructions:	Hydration should be administered prior to chemotherapy.			Pre-Medications
☑	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once for 1 dose			Offset: 0 Hours	Instructions:	Administer 30 minutes prior to chemotherapy via slow IVP.		☐	diphenhydrAMINE (BENADRYL) 50 mg in sodium chloride 0.9% 50 mL IVPB	Dose: 50 mg	Route: intravenous	once over 15 Minutes for 1 dose	Start: S	End: S 11:00 AM		Instructions:	Administer 30 minutes prior to chemotherapy	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION	Medications	50 mg	Main Ingredient	No	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	50 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	50 mL	No	Yes			☐	diphenhydrAMINE (BENADRYL) tablet 25 mg	Dose: 25 mg	Route: oral	once for 1 dose			Offset: 0 Hours	Instructions:	Administer 30 minutes prior to chemotherapy.		☑	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 30 minutes prior to chemotherapy		☐	famotidine (PEPCID) tablet 20 mg	Dose: 20 mg	Route: oral	once for 1 dose			Offset: 0 Hours	Instructions:	Administer 30 minutes prior to chemotherapy.		☐	dexAMETHasone (DECADRON) IV 20 mg	Dose: 20 mg	Route: intravenous	once for 1 dose						Pre-Medications
☑	ondansetron (ZOFRAN) 16 mg, dexamethasone (DECADRON) 12 mg in sodium chloride 0.9% 50 mL IVPB	Dose: 16 mg	Route: intravenous	once over 10 Minutes for 1 dose	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION	Medications	16 mg	Main Ingredient	No	DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION	Medications	12 mg	Yes	No	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	50 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	50 mL	No	Yes			☑	fosaprepitant (EMEND) IVPB 150 mg	Dose: 150 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S					Pre-Medications
◯	LORazepam (ATIVAN) tablet 1 mg	Dose: 1 mg	Route: oral	once for 1 dose	Start: S					Chemotherapy
  	PACLItaxel (TAXOL) 175 mg/m2 in sodium chloride (NON-PVC) 0.9 % 500 mL chemo IVPB	Dose: 175 mg/m2	Route: intravenous	once over 3 Hours for 1 dose			Offset: 60 Minutes	Instructions:	Administer through a 0.22 micron filter and non-PVC tubing set.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS	Medications	175 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % IV SOLP (EXCEL;NON-PVC)	QS Base	500 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) IV SOLP (EXCEL; NON-PVC)	QS Base	 	No	Yes			  	CISplatin (PLATINOL) 75 mg/m2 in sodium chloride 0.9% 500 mL chemo IVPB	Dose: 75 mg/m2	Route: intravenous	once over 1 Hours for 1 dose			Offset: 4 Hours	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION	Medications	75 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	500 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	500 mL	No	Yes				Post-Hydration
◯	sodium chloride 0.9 % infusion 1,000 mL	Dose: 1,000 mL	Route: intravenous	once @ 250 mL/hr for 1 dose			Offset: 5.5 Hours	Instructions:	Following chemotherapy.			Discharge Nursing Orders
☑	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN					☑	HEParin, porcine (PF) injection 500 Units	Dose: 500 Units	Route: intra-catheter	once PRN	Start: S			Instructions:	Concentration: 100 units/mL. Heparin flush for Implanted Vascular Access Device maintenance.			Post-Medications
◯	filgrastim-sndz (ZARXIO) injection solution	Dose: --	Route: subcutaneous		Start: S+1			Rule-Based Template: RULE ONCBCN NEUPOGEN WEIGHT BASED	  Conditions:	  Modifications:	  Weight > 78 kg	  Set dose to 480 mcg	  Weight <= 78 kg	  Set dose to 300 mcg