Date/time: ______________________ allergies: _______________________

Nursing Care: (Check box/ fill in to activate)
Oral Care: NS mouth rinse every 4 hours and PRN Vitals every 4 hours Vitals every shift Guaiac stools Call physician if temp greater than Call physician if patient neutropenic and temp greater than 38° C
Activity: (Check box to activate)
Up ad lib Strict bedrest Up w/ assist Ambulate in hallway
Diet: (Check box/ fill in to activate)
Lab/ Diagnostics: (Check box/ fill in to activate)
Labs not needed, done within past 48 hrs. Proceed with chemotherapy Wait for result(s)/ parameters CBC CBC w/ diff (CD) CMP BMP Call MD if: HCT less than ________
IV Fluids: (Fill in to activate)

PRE-chemotherapy hydration orders:

Maintenance and POST-chemotherapy hydration orders:
Sign Date Time
CHEMOTHERAPY ORDERS Page 1 of 3
P0162B (Rev 1108) White – chart Yellow- Pharmacy Pink – Nursing
Medication Therapy: (Check box/ fill in to activate)

Dalteparin (Fragmin) 5000 international units SubQ every 24 hours (prophylaxis)
Heparin 5000 units SubQ every 8 hours (prophylaxis) Enoxaparin (Lovenox) 40 mg SubQ every 24 hours (prophylaxis)
Enoxaparin (Lovenox) 1 mg/ kg SubQ every 12 hours (full dose)
Warfarin (Coumadin) per Pharmacy. INR Goal is:
ROUTINE MEDS Intermittent pneumatic compression (SCDs)
Diphenhydramine (Benadryl) mg IV prior to initial chemotherapy, then
Famotidine (Pepcid) 20 mg IV prior to initial chemotherapy, then
Acetaminophen (Tylenol)
mg PO prior to initial chemotherapy, then MEDICATIONS Ondansetron (Zofran) _________ mg IV 30 minutes prior to chemotherapy, then
Dexamethasone (Decadron)
Aprepitant (Emend) 125 mg PO day 1 prior to chemotherapy, then 80 mg PO days 2 and 3 after chemotherapy Nausea / Vomiting
PRECHEMO Other:
Ondansetron (Zofran) ________mg IV every _________ hours PRN
Prochlorperazine (Compazine) 5 - 10 mg PO/ IV every 6 hrs PRN if ondansetron (Zofran) ordered/ ineffective
Lorazepam (Ativan) 0.5 – 2 mg PO/ IV every 4 hours PRN
Acetaminophen (Tylenol) 325 – 975 mg PO every 4 hrs PRN. Not to exceed 4 g of acetaminophen/ 24 hrs
Zolpidem (Ambien) 5 mg PO HS PRN insomnia (use 2.5 mg if 65 or older). May repeat X 1
Senna/ docusate (Senokot-S) 8.6 mg/ 50 mg 2 tablets PO BID and Docusate 250mg PO BID (hold for loose
stools). MOM Concentrate 10 mL PO daily PRN. If ineffective, give Polyethylene glycol (Miralax equiv) 17 g
PRN MEDICATIONS PO daily PRN
Loperamide (Imodium) 4 mg PO initially, then 2 mg PO after each loose stool up to a maximum of 16
For symptoms of anaphylaxis, or for severe medication reaction, notify physician and administer the
▪ Diphenhydramine (Benadryl) 25 mg IV X 1. May repeat X 1 in 10 minutes
PRN RXN ▪ Dexamethasone (Decadron) 10 mg IV X1


Discharge Planning: (Check box to activate)
Initiate Outpatient Anticoagulation Orders (P0190) Sign Date Time

CHEMOTHERAPY ORDERS Page 2 of 3
P0162B (Rev 1108) White – chart Yellow- Pharmacy Pink – Nursing
Diagnosis:
Treatment Regimen: (please provide reference if new regimen or if varying from known protocol)
Body Surface Area:
Kg ft Inches M
CHEMOTHERAPY: Administer chemotherapy in the following sequence unless otherwise specified by physician
Diluent and rate per Pharmacy chemotherapy preparation and administrative guidelines unless otherwise written by physician Dose reduced based on patient’s reaction or response to previous treatment(s) Dose reduced based on renal or hepatic dysfunction Dose reduced based on patient’s reaction or response to previous treatment(s) Dose reduced based on renal or hepatic dysfunction Dose reduced based on patient’s reaction or response to previous treatment(s) Dose reduced based on renal or hepatic dysfunction Dose reduced based on patient’s reaction or response to previous treatment(s) Dose reduced based on renal or hepatic dysfunction Dose reduced based on patient’s reaction or response to previous treatment(s) Dose reduced based on renal or hepatic dysfunction Physician Signature
CHEMOTHERAPY ORDERS Page 3 of 3
P0162B (Rev 1108) White – chart Yellow- Pharmacy Pink – Nursing

Source: http://www4.overlakehospital.org/physforms/content/ONCOLOGY_CHEMOTX(P0162B).pdf