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CSC GU Atezolizumab(21D:1) VER 12-1-16 (HL 5540)

CSC GU Atezolizumab(21D:1) VER 12-1-16 (HL 5540) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GU


CSC GU ATEZOLIZUMAB(21D1) VER 12-1-16 – Properties
Pre-Cycle – 6/7/2017 through 6/13/2017 (7 days), Planned
Day 1, Pre-Cycle – Planned for 6/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Urothelial Carcinoma (Advanced); THERAPY: atezolizumab 1200 mg IV Day 1; CYCLE LENGTH: 21 days; COURSE:
until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S Approximate, Expires-S+397, Routine
GLUCOSE
Expected-S Approximate, Expires-S+397, Routine
BUN
Expected-S Approximate, Expires-S+397, Routine
CREATININE
Expected-S Approximate, Expires-S+397, Routine
CALCIUM
Expected-S Approximate, Expires-S+397, Routine
ALBUMIN
Expected-S Approximate, Expires-S+397, Routine
PROTEIN, TOTAL
Expected-S Approximate, Expires-S+397, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+397, Routine
AST/SGOT
Expected-S Approximate, Expires-S+397, Routine
ALT/SGPT
Expected-S Approximate, Expires-S+397, Routine
ALKALINE PHOSPHATASE
Expected-S Approximate, Expires-S+397, Routine
LIPASE
Expected-S Approximate, Expires-S+365, Routine
AMYLASE
Expected-S Approximate, Expires-S+365, Routine
TSH
Expected-S Approximate, Expires-S+365, Routine
T4, FREE
Expected-S Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
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Zztestonc,Jeff J [2507481]
6/14/2017 3:51:06 PM Page 1 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

HCG, QUALITATIVE, URINE
Expected-S Approximate, Expires-S+122, Routine
Cycle 1 – 6/14/2017 through 7/4/2017 (21 days), Planned
Day 1, Cycle 1 – Planned for 6/14/2017
Treatment Plan Information
Reference Information (1)
UROTHELIAL CARCINOMA: Rosenberg JE, et al. Lancet 2016;387(10031):1909-20.
Treatment Plan Summary
DISEASE: Urothelial Carcinoma (Advanced); THERAPY: atezolizumab 1200 mg IV Day 1; CYCLE LENGTH: 21 days; COURSE:
until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: AST, ALT, Total Bilirubin, Amylase, Lipase.
Treatment Parameters
Hold treatment and notify authorizing prescriber for AST greater than 3 X ULN (greater than 5 X ULN if known liver metastases) or
ALT greater than 3 X ULN (greater than 5 X ULN if known liver metastases) or Total Bilirubin greater than 1.5 X ULN or Amylase
greater than 2 X ULN or Lipase greater than 2 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to atezolizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Patient Instructions(1)
Advise patients to contact provider right away with signs of pneumonitis (new or worse cough, chest pain or shortness of breath) or
colitis (abdominal pain; mucus or blood in stool).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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Zztestonc,Jeff J [2507481]
6/14/2017 3:51:06 PM Page 2 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
atezolizumab (TECENTRIQ) 1,200 mg in sodium chloride 0.9 % 250 mL bag
1,200 mg, Intravenous, ONCE, 1 dose Starting when released
Administer as an IV infusion over 60 minutes. If the first infusion is tolerated, all subsequent infusions can be given over 30 minutes.
Do not administer IV push or IV bolus. Do not shake. Do not co-administer other drugs through same intravenous line.
Hypersensitivity reaction to atezolizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC, Electrolytes, Glucose, BUN, Creatinine,
Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Lipase, Amylase; LABS (EVEN CYCLES ONLY):
TSH, Free T4, CHEMOTHERAPY ROOM APPOINTMENT: atezolizumab for 60 minutes.
Cycle 2 – 7/5/2017 through 7/25/2017 (21 days), Planned
Day 1, Cycle 2 – Planned for 7/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Urothelial Carcinoma (Advanced); THERAPY: atezolizumab 1200 mg IV Day 1; CYCLE LENGTH: 21 days; COURSE:
until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
GLUCOSE
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
BUN
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
CALCIUM
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Zztestonc,Jeff J [2507481]
6/14/2017 3:51:06 PM Page 3 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Expected-S+21 Approximate, Expires-S+365, Normal, Routine
ALBUMIN
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
PROTEIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
LIPASE
Expected-S+21, Expires-S+365, Routine
AMYLASE
Expected-S+21, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
TSH
Expected-S+21, Expires-S+365, Routine
Prior to EVEN cycles only.
T4, FREE
Expected-S+21, Expires-S+365, Routine
Prior to EVEN cycles only.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: AST, ALT, Total Bilirubin, Amylase, Lipase.
Treatment Parameters
Hold treatment and notify authorizing prescriber for AST greater than 3 X ULN (greater than 5 X ULN if known liver metastases) or
ALT greater than 3 X ULN (greater than 5 X ULN if known liver metastases) or Total Bilirubin greater than 1.5 X ULN or Amylase
greater than 2 X ULN or Lipase greater than 2 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to atezolizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Patient Instructions(1)
Advise patients to contact provider right away with signs of pneumonitis (new or worse cough, chest pain or shortness of breath) or
colitis (abdominal pain; mucus or blood in stool).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
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Zztestonc,Jeff J [2507481]
6/14/2017 3:51:06 PM Page 4 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
atezolizumab (TECENTRIQ) 1,200 mg in sodium chloride 0.9 % 250 mL bag
1,200 mg, Intravenous, ONCE, 1 dose Starting when released
Administer as an IV infusion over 60 minutes. If the first infusion is tolerated, all subsequent infusions can be given over 30 minutes.
Do not administer IV push or IV bolus. Do not shake. Do not co-administer other drugs through same intravenous line.
Hypersensitivity reaction to atezolizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC, Electrolytes, Glucose, BUN, Creatinine,
Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Lipase, Amylase; LABS (EVEN CYCLES ONLY):
TSH, Free T4, CHEMOTHERAPY ROOM APPOINTMENT: atezolizumab for 60 minutes.
Cycle 3 – 7/26/2017 through 8/15/2017 (21 days), Planned
Day 1, Cycle 3 – Planned for 7/26/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Urothelial Carcinoma (Advanced); THERAPY: atezolizumab 1200 mg IV Day 1; CYCLE LENGTH: 21 days; COURSE:
until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
GLUCOSE
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
BUN
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
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Zztestonc,Jeff J [2507481]
6/14/2017 3:51:06 PM Page 5 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

CREATININE
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
CALCIUM
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
ALBUMIN
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
PROTEIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
LIPASE
Expected-S+21, Expires-S+365, Routine
AMYLASE
Expected-S+21, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
TSH
Expected-S+21, Expires-S+365, Routine
Prior to EVEN cycles only.
T4, FREE
Expected-S+21, Expires-S+365, Routine
Prior to EVEN cycles only.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: AST, ALT, Total Bilirubin, Amylase, Lipase.
Treatment Parameters
Hold treatment and notify authorizing prescriber for AST greater than 3 X ULN (greater than 5 X ULN if known liver metastases) or
ALT greater than 3 X ULN (greater than 5 X ULN if known liver metastases) or Total Bilirubin greater than 1.5 X ULN or Amylase
greater than 2 X ULN or Lipase greater than 2 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to atezolizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Patient Instructions(1)
Advise patients to contact provider right away with signs of pneumonitis (new or worse cough, chest pain or shortness of breath) or
colitis (abdominal pain; mucus or blood in stool).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
Actions
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Zztestonc,Jeff J [2507481]
6/14/2017 3:51:06 PM Page 6 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
atezolizumab (TECENTRIQ) 1,200 mg in sodium chloride 0.9 % 250 mL bag
1,200 mg, Intravenous, ONCE, 1 dose Starting when released
Administer as an IV infusion over 60 minutes. If the first infusion is tolerated, all subsequent infusions can be given over 30 minutes.
Do not administer IV push or IV bolus. Do not shake. Do not co-administer other drugs through same intravenous line.
Hypersensitivity reaction to atezolizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC, Electrolytes, Glucose, BUN, Creatinine,
Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Lipase, Amylase; LABS (EVEN CYCLES ONLY):
TSH, Free T4, CHEMOTHERAPY ROOM APPOINTMENT: atezolizumab for 60 minutes.
Cycle 4 – 8/16/2017 through 9/5/2017 (21 days), Planned
Day 1, Cycle 4 – Planned for 8/16/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Urothelial Carcinoma (Advanced); THERAPY: atezolizumab 1200 mg IV Day 1; CYCLE LENGTH: 21 days; COURSE:
until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
GLUCOSE
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
Actions
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Zztestonc,Jeff J [2507481]
6/14/2017 3:51:06 PM Page 7 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

BUN
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
CALCIUM
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
ALBUMIN
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
PROTEIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
LIPASE
Expected-S+21, Expires-S+365, Routine
AMYLASE
Expected-S+21, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
TSH
Expected-S+21, Expires-S+365, Routine
Prior to EVEN cycles only.
T4, FREE
Expected-S+21, Expires-S+365, Routine
Prior to EVEN cycles only.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: AST, ALT, Total Bilirubin, Amylase, Lipase.
Treatment Parameters
Hold treatment and notify authorizing prescriber for AST greater than 3 X ULN (greater than 5 X ULN if known liver metastases) or
ALT greater than 3 X ULN (greater than 5 X ULN if known liver metastases) or Total Bilirubin greater than 1.5 X ULN or Amylase
greater than 2 X ULN or Lipase greater than 2 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to atezolizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Patient Instructions(1)
Advise patients to contact provider right away with signs of pneumonitis (new or worse cough, chest pain or shortness of breath) or
colitis (abdominal pain; mucus or blood in stool).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
Actions
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Zztestonc,Jeff J [2507481]
6/14/2017 3:51:06 PM Page 8 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
atezolizumab (TECENTRIQ) 1,200 mg in sodium chloride 0.9 % 250 mL bag
1,200 mg, Intravenous, ONCE, 1 dose Starting when released
Administer as an IV infusion over 60 minutes. If the first infusion is tolerated, all subsequent infusions can be given over 30 minutes.
Do not administer IV push or IV bolus. Do not shake. Do not co-administer other drugs through same intravenous line.
Hypersensitivity reaction to atezolizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC, Electrolytes, Glucose, BUN, Creatinine,
Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Lipase, Amylase; LABS (EVEN CYCLES ONLY):
TSH, Free T4, CHEMOTHERAPY ROOM APPOINTMENT: atezolizumab for 60 minutes.
Cycle 5 – 9/6/2017 through 9/26/2017 (21 days), Planned
Day 1, Cycle 5 – Planned for 9/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Urothelial Carcinoma (Advanced); THERAPY: atezolizumab 1200 mg IV Day 1; CYCLE LENGTH: 21 days; COURSE:
until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
ELECTROLYTES
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Zztestonc,Jeff J [2507481]
6/14/2017 3:51:06 PM Page 9 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Expected-S+21 Approximate, Expires-S+365, Normal, Routine
GLUCOSE
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
BUN
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
CALCIUM
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
ALBUMIN
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
PROTEIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
LIPASE
Expected-S+21, Expires-S+365, Routine
AMYLASE
Expected-S+21, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
TSH
Expected-S+21, Expires-S+365, Routine
Prior to EVEN cycles only.
T4, FREE
Expected-S+21, Expires-S+365, Routine
Prior to EVEN cycles only.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: AST, ALT, Total Bilirubin, Amylase, Lipase.
Treatment Parameters
Hold treatment and notify authorizing prescriber for AST greater than 3 X ULN (greater than 5 X ULN if known liver metastases) or
ALT greater than 3 X ULN (greater than 5 X ULN if known liver metastases) or Total Bilirubin greater than 1.5 X ULN or Amylase
greater than 2 X ULN or Lipase greater than 2 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to atezolizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Patient Instructions(1)
Advise patients to contact provider right away with signs of pneumonitis (new or worse cough, chest pain or shortness of breath) or
colitis (abdominal pain; mucus or blood in stool).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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Zztestonc,Jeff J [2507481]
6/14/2017 3:51:06 PM Page 10 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
atezolizumab (TECENTRIQ) 1,200 mg in sodium chloride 0.9 % 250 mL bag
1,200 mg, Intravenous, ONCE, 1 dose Starting when released
Administer as an IV infusion over 60 minutes. If the first infusion is tolerated, all subsequent infusions can be given over 30 minutes.
Do not administer IV push or IV bolus. Do not shake. Do not co-administer other drugs through same intravenous line.
Hypersensitivity reaction to atezolizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC, Electrolytes, Glucose, BUN, Creatinine,
Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Lipase, Amylase; LABS (EVEN CYCLES ONLY):
TSH, Free T4, CHEMOTHERAPY ROOM APPOINTMENT: atezolizumab for 60 minutes.
Cycle 6 – 9/27/2017 through 10/17/2017 (21 days), Planned
Day 1, Cycle 6 – Planned for 9/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Urothelial Carcinoma (Advanced); THERAPY: atezolizumab 1200 mg IV Day 1; CYCLE LENGTH: 21 days; COURSE:
until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
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Zztestonc,Jeff J [2507481]
6/14/2017 3:51:06 PM Page 11 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
GLUCOSE
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
BUN
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
CALCIUM
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
ALBUMIN
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
PROTEIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
LIPASE
Expected-S+21, Expires-S+365, Routine
AMYLASE
Expected-S+21, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
TSH
Expected-S+21, Expires-S+365, Routine
Prior to EVEN cycles only.
T4, FREE
Expected-S+21, Expires-S+365, Routine
Prior to EVEN cycles only.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: AST, ALT, Total Bilirubin, Amylase, Lipase.
Treatment Parameters
Hold treatment and notify authorizing prescriber for AST greater than 3 X ULN (greater than 5 X ULN if known liver metastases) or
ALT greater than 3 X ULN (greater than 5 X ULN if known liver metastases) or Total Bilirubin greater than 1.5 X ULN or Amylase
greater than 2 X ULN or Lipase greater than 2 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to atezolizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Patient Instructions(1)
Advise patients to contact provider right away with signs of pneumonitis (new or worse cough, chest pain or shortness of breath) or
colitis (abdominal pain; mucus or blood in stool).
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Zztestonc,Jeff J [2507481]
6/14/2017 3:51:06 PM Page 12 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
atezolizumab (TECENTRIQ) 1,200 mg in sodium chloride 0.9 % 250 mL bag
1,200 mg, Intravenous, ONCE, 1 dose Starting when released
Administer as an IV infusion over 60 minutes. If the first infusion is tolerated, all subsequent infusions can be given over 30 minutes.
Do not administer IV push or IV bolus. Do not shake. Do not co-administer other drugs through same intravenous line.
Hypersensitivity reaction to atezolizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC, Electrolytes, Glucose, BUN, Creatinine,
Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Lipase, Amylase; LABS (EVEN CYCLES ONLY):
TSH, Free T4, CHEMOTHERAPY ROOM APPOINTMENT: atezolizumab for 60 minutes.
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Zztestonc,Jeff J [2507481]
6/14/2017 3:51:06 PM Page 13 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org