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CSC GU Pembrolizumab(21D:1) VER 6-27-17 (HL 5970)

CSC GU Pembrolizumab(21D:1) VER 6-27-17 (HL 5970) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GU


CSC GU PEMBROLIZUMAB(21D:1) VER: 6-27-17 – Properties
Pre-Cycle – 6/20/2017 through 6/26/2017 (7 days), Planned
Day 1, Pre-Cycle – Planned for 6/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Urothelial Cancer (Advanced); THERAPY: pembrolizumab 200 mg IV Day 1; CYCLE LENGTH: 21 days; COURSE: until
disease progression (maximum of 24 months).
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
Baseline and prior to every EVEN Cycle only.
T4, FREE
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Zztestonc,Fiona F [2462287]
6/27/2017 2:21:30 PM Page 1 of 14
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Expected-S Approximate, Expires-S+365, Routine
Baseline and prior to every EVEN Cycle only.
Take Home Medications
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed for nausea/vomiting., 8 mg, Disp-30 tab, R-5, EVERY 8 HOURS PRN starting S,
Local Printer
prochlorperazine (COMPAZINE) 10 MG tab
Take 1 tab by mouth every 6 hours as needed for nausea/vomiting., 10 mg, Disp-30 tab, R-5, EVERY 6 HOURS PRN starting S,
Local Printer
Cycle 1 – 6/27/2017 through 7/17/2017 (21 days), Planned
Day 1, Cycle 1 – Planned for 6/27/2017
Treatment Plan Information
Reference Information (1)
UROTHELIAL CARCINOMA: Bellmunt J, et al. N Engl J Med 2017;376(11):1015-26.
Reference Information (2)
UROTHELIAL CARCINOMA: O'Donnell PH, et al. J Clin Oncol 2017;35(suppl;abstr 4502).
Treatment Plan Summary
DISEASE: Urothelial Cancer (Advanced); THERAPY: pembrolizumab 200 mg IV Day 1; CYCLE LENGTH: 21 days; COURSE: until
disease progression (maximum of 24 months).
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: CBC, ANC, Creatinine, AST, ALT, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than 1.5 X ULN or AST greater than 2.5 X ULN (or greater than 5 X ULN if known liver metastases) or ALT greater than 2.5
X ULN (or greater than 5 X ULN if known liver metastases) or Total Bilirubin greater than 1.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to pembrolizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications. Patient must be monitored for 30 minutes after first dose of pembrolizumab.
Monitoring Parameters (1)
Notify MD for Systolic Blood Pressure below 100 mmHg (if below pre-infusion Blood Pressure) or for any symptoms of hypotension.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor Blood Pressure, Heart Rate, Temperature, Respiratory Rate and Pain Level every 15 minutes during pembrolizumab
infusion. Also monitor blood pressure, heart rate, temperature, respiratory rate and pain level 30 minutes after end of first
pembrolizumab infusion.
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.
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Zztestonc,Fiona F [2462287]
6/27/2017 2:21:30 PM Page 2 of 14
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
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
pembrolizumab (KEYTRUDA) 200 mg in sodium chloride 0.9 % 50 mL bag
200 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes with 0.2 or 0.22 micron filter. Do not co-administer other drugs through same infusion line.
Hypersensitivity reaction to pembrolizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications. Patient must be monitored for 30 minutes after first dose of pembrolizumab.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Electrolytes,
Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Lipase, Amylase;
LABS (prior to every EVEN cycle only): TSH, Free T4; CHEMOTHERAPY ROOM APPOINTMENT: pembrolizumab for 60 minutes.
Cycle 2 – 7/18/2017 through 8/7/2017 (21 days), Planned
Day 1, Cycle 2 – Planned for 7/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Urothelial Cancer (Advanced); THERAPY: pembrolizumab 200 mg IV Day 1; CYCLE LENGTH: 21 days; COURSE: until
disease progression (maximum of 24 months).
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Fiona F [2462287]
6/27/2017 2:21:30 PM Page 3 of 14
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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 WITH DIFFERENTIAL
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 Approximate, Expires-S+365, Routine
Baseline and prior to every EVEN Cycle only.
T4, FREE
Expected-S+21 Approximate, Expires-S+365, Routine
Baseline and prior to every EVEN Cycle only.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, ALT, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than 1.5 X ULN or AST greater than 2.5 X ULN (or greater than 5 X ULN if known liver metastases) or ALT greater than 2.5
X ULN (or greater than 5 X ULN if known liver metastases) or Total Bilirubin greater than 1.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
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Zztestonc,Fiona F [2462287]
6/27/2017 2:21:30 PM Page 4 of 14
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Hypersensitivity reaction to pembrolizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications. Patient must be monitored for 30 minutes after first dose of pembrolizumab.
Monitoring Parameters (1)
Notify MD for Systolic Blood Pressure below 100 mmHg (if below pre-infusion Blood Pressure) or for any symptoms of hypotension.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor Blood Pressure, Heart Rate, Temperature, Respiratory Rate and Pain Level every 15 minutes during pembrolizumab
infusion. Also monitor blood pressure, heart rate, temperature, respiratory rate and pain level 30 minutes after end of first
pembrolizumab infusion.
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
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
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
pembrolizumab (KEYTRUDA) 200 mg in sodium chloride 0.9 % 50 mL bag
200 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes with 0.2 or 0.22 micron filter. Do not co-administer other drugs through same infusion line.
Hypersensitivity reaction to pembrolizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications. Patient must be monitored for 30 minutes after first dose of pembrolizumab.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Electrolytes,
Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Lipase, Amylase;
LABS (prior to every EVEN cycle only): TSH, Free T4; CHEMOTHERAPY ROOM APPOINTMENT: pembrolizumab for 60 minutes.
Cycle 3 – 8/8/2017 through 8/28/2017 (21 days), Planned
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Zztestonc,Fiona F [2462287]
6/27/2017 2:21:30 PM Page 5 of 14
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Day 1, Cycle 3 – Planned for 8/8/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Urothelial Cancer (Advanced); THERAPY: pembrolizumab 200 mg IV Day 1; CYCLE LENGTH: 21 days; COURSE: until
disease progression (maximum of 24 months).
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.
Pre-Labs
CBC WITH DIFFERENTIAL
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 Approximate, Expires-S+365, Routine
Baseline and prior to every EVEN Cycle only.
T4, FREE
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Zztestonc,Fiona F [2462287]
6/27/2017 2:21:30 PM Page 6 of 14
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, Routine
Baseline and prior to every EVEN Cycle only.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, ALT, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than 1.5 X ULN or AST greater than 2.5 X ULN (or greater than 5 X ULN if known liver metastases) or ALT greater than 2.5
X ULN (or greater than 5 X ULN if known liver metastases) or Total Bilirubin greater than 1.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to pembrolizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications. Patient must be monitored for 30 minutes after first dose of pembrolizumab.
Monitoring Parameters (1)
Notify MD for Systolic Blood Pressure below 100 mmHg (if below pre-infusion Blood Pressure) or for any symptoms of hypotension.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor Blood Pressure, Heart Rate, Temperature, Respiratory Rate and Pain Level every 15 minutes during pembrolizumab
infusion. Also monitor blood pressure, heart rate, temperature, respiratory rate and pain level 30 minutes after end of first
pembrolizumab infusion.
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
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
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
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Zztestonc,Fiona F [2462287]
6/27/2017 2:21:30 PM Page 7 of 14
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

pembrolizumab (KEYTRUDA) 200 mg in sodium chloride 0.9 % 50 mL bag
200 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes with 0.2 or 0.22 micron filter. Do not co-administer other drugs through same infusion
line. Hypersensitivity reaction to pembrolizumab can occur. For first and second dose, patient should be treated in a
location to optimize emergency care. See Emergency Medications. Patient must be monitored for 30 minutes after
first dose of pembrolizumab.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Electrolytes,
Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Lipase, Amylase;
LABS (prior to every EVEN cycle only): TSH, Free T4; CHEMOTHERAPY ROOM APPOINTMENT: pembrolizumab for 60 minutes.
Cycle 4 – 8/29/2017 through 9/18/2017 (21 days), Planned
Day 1, Cycle 4 – Planned for 8/29/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Urothelial Cancer (Advanced); THERAPY: pembrolizumab 200 mg IV Day 1; CYCLE LENGTH: 21 days; COURSE: until
disease progression (maximum of 24 months).
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.
Pre-Labs
CBC WITH DIFFERENTIAL
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
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Zztestonc,Fiona F [2462287]
6/27/2017 2:21:30 PM Page 8 of 14
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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 Approximate, Expires-S+365, Routine
Baseline and prior to every EVEN Cycle only.
T4, FREE
Expected-S+21 Approximate, Expires-S+365, Routine
Baseline and prior to every EVEN Cycle only.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, ALT, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than 1.5 X ULN or AST greater than 2.5 X ULN (or greater than 5 X ULN if known liver metastases) or ALT greater than 2.5
X ULN (or greater than 5 X ULN if known liver metastases) or Total Bilirubin greater than 1.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to pembrolizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications. Patient must be monitored for 30 minutes after first dose of pembrolizumab.
Monitoring Parameters (1)
Notify MD for Systolic Blood Pressure below 100 mmHg (if below pre-infusion Blood Pressure) or for any symptoms of hypotension.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor Blood Pressure, Heart Rate, Temperature, Respiratory Rate and Pain Level every 15 minutes during pembrolizumab
infusion. Also monitor blood pressure, heart rate, temperature, respiratory rate and pain level 30 minutes after end of first
pembrolizumab infusion.
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
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Emergency Medications
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Zztestonc,Fiona F [2462287]
6/27/2017 2:21:30 PM Page 9 of 14
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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
pembrolizumab (KEYTRUDA) 200 mg in sodium chloride 0.9 % 50 mL bag
200 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes with 0.2 or 0.22 micron filter. Do not co-administer other drugs through same infusion line.
Hypersensitivity reaction to pembrolizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications. Patient must be monitored for 30 minutes after first dose of pembrolizumab.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Electrolytes,
Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Lipase, Amylase;
LABS (prior to every EVEN cycle only): TSH, Free T4; CHEMOTHERAPY ROOM APPOINTMENT: pembrolizumab for 60 minutes.
Cycle 5 – 9/19/2017 through 10/9/2017 (21 days), Planned
Day 1, Cycle 5 – Planned for 9/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Urothelial Cancer (Advanced); THERAPY: pembrolizumab 200 mg IV Day 1; CYCLE LENGTH: 21 days; COURSE: until
disease progression (maximum of 24 months).
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.
Pre-Labs
CBC WITH DIFFERENTIAL
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
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Zztestonc,Fiona F [2462287]
6/27/2017 2:21:30 PM Page 10 of 14
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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 Approximate, Expires-S+365, Routine
Baseline and prior to every EVEN Cycle only.
T4, FREE
Expected-S+21 Approximate, Expires-S+365, Routine
Baseline and prior to every EVEN Cycle only.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, ALT, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than 1.5 X ULN or AST greater than 2.5 X ULN (or greater than 5 X ULN if known liver metastases) or ALT greater than 2.5
X ULN (or greater than 5 X ULN if known liver metastases) or Total Bilirubin greater than 1.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to pembrolizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications. Patient must be monitored for 30 minutes after first dose of pembrolizumab.
Monitoring Parameters (1)
Notify MD for Systolic Blood Pressure below 100 mmHg (if below pre-infusion Blood Pressure) or for any symptoms of hypotension.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor Blood Pressure, Heart Rate, Temperature, Respiratory Rate and Pain Level every 15 minutes during pembrolizumab
infusion. Also monitor blood pressure, heart rate, temperature, respiratory rate and pain level 30 minutes after end of first
pembrolizumab infusion.
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
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Zztestonc,Fiona F [2462287]
6/27/2017 2:21:30 PM Page 11 of 14
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
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
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
pembrolizumab (KEYTRUDA) 200 mg in sodium chloride 0.9 % 50 mL bag
200 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes with 0.2 or 0.22 micron filter. Do not co-administer other drugs through same infusion line.
Hypersensitivity reaction to pembrolizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications. Patient must be monitored for 30 minutes after first dose of pembrolizumab.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Electrolytes,
Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Lipase, Amylase;
LABS (prior to every EVEN cycle only): TSH, Free T4; CHEMOTHERAPY ROOM APPOINTMENT: pembrolizumab for 60 minutes.
Cycle 6 – 10/10/2017 through 10/30/2017 (21 days), Planned
Day 1, Cycle 6 – Planned for 10/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Urothelial Cancer (Advanced); THERAPY: pembrolizumab 200 mg IV Day 1; CYCLE LENGTH: 21 days; COURSE: until
disease progression (maximum of 24 months).
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.
Pre-Labs
CBC WITH DIFFERENTIAL
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Zztestonc,Fiona F [2462287]
6/27/2017 2:21:30 PM Page 12 of 14
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, 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 Approximate, Expires-S+365, Routine
Baseline and prior to every EVEN Cycle only.
T4, FREE
Expected-S+21 Approximate, Expires-S+365, Routine
Baseline and prior to every EVEN Cycle only.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, ALT, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than 1.5 X ULN or AST greater than 2.5 X ULN (or greater than 5 X ULN if known liver metastases) or ALT greater than 2.5
X ULN (or greater than 5 X ULN if known liver metastases) or Total Bilirubin greater than 1.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to pembrolizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications. Patient must be monitored for 30 minutes after first dose of pembrolizumab.
Monitoring Parameters (1)
Notify MD for Systolic Blood Pressure below 100 mmHg (if below pre-infusion Blood Pressure) or for any symptoms of hypotension.
Vital Signs
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Zztestonc,Fiona F [2462287]
6/27/2017 2:21:30 PM Page 13 of 14
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

SEE COMMENTS Starting when released Until Specified
Monitor Blood Pressure, Heart Rate, Temperature, Respiratory Rate and Pain Level every 15 minutes during pembrolizumab
infusion. Also monitor blood pressure, heart rate, temperature, respiratory rate and pain level 30 minutes after end of first
pembrolizumab infusion.
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
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
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
pembrolizumab (KEYTRUDA) 200 mg in sodium chloride 0.9 % 50 mL bag
200 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes with 0.2 or 0.22 micron filter. Do not co-administer other drugs through same infusion line.
Hypersensitivity reaction to pembrolizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications. Patient must be monitored for 30 minutes after first dose of pembrolizumab.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Electrolytes,
Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Lipase, Amylase;
LABS (prior to every EVEN cycle only): TSH, Free T4; CHEMOTHERAPY ROOM APPOINTMENT: pembrolizumab for 60 minutes.
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Zztestonc,Fiona F [2462287]
6/27/2017 2:21:30 PM Page 14 of 14
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org