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201706166

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100

UWHC,UWMF,

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Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Beacon Protocols,GU

CSC GU Interferon Alfa-2B(28D:3xWeekly) Clinic-Administered VER 12-1-16 (HL 750)

CSC GU Interferon Alfa-2B(28D:3xWeekly) Clinic-Administered VER 12-1-16 (HL 750) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GU


CSC GU INTERFERON ALFA-2B(28D:3XWEEKLY) CLINIC-ADMINISTERED VER: 12-1-16 (HL 750) – Properties
Pre-Cycle – 6/8/2017 through 6/14/2017 (7 days), Planned
Day 1, Pre-Cycle – Planned for 6/8/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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
CREATININE
Expected-S Approximate, Expires-S+365, Routine
Take Home Medications
acetaMINOPHEN (TYLENOL) 325 MG tab
Take 1-2 tabs by mouth every 4 hours as needed for fever or pain., 325-650 mg, Disp-100 tab, R-6, EVERY 4 HOURS PRN
starting S
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
Cycle 1 – 6/15/2017 through 7/12/2017 (28 days), Planned
Day 1, Cycle 1 – Planned for 6/15/2017
Treatment Plan Information
Reference Information (1)
RENAL CANCER: Quesada JR, et al. J Clin Oncol 1985;3:1522-8.
Reference Information (2)
RENAL CANCER: Muss HB, et al. J Clin Oncol 1987;5:286-91.
Reference Information (3)
RENAL CANCER: Flanigan RC, et al. N Engl J Med 2001;345:1655-9
Reference Information (4)
RENAL CANCER: Mickisch GHJ, et al. Lancet 2001;358:966-70.
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Jeff J [2507481]
6/15/2017 7:58:44 AM Page 1 of 49
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.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
MULTIPLE DAY FOLLOW-UP (1)
DAY 3 AND 5 FOLLOW-UP; CHEMOTHERAPY ROOM APPOINTMENT: interferon alfa-2B SC injection for 30 minutes.
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally); CHEMOTHERAPY ROOM APPOINTMENT: interferon alfa-2B SC injection for 30 minutes.
MULTIPLE DAY FOLLOW-UP (2)
DAY 10 AND 12 FOLLOW-UP; CHEMOTHERAPY ROOM APPOINTMENT: interferon alfa-2B SC injection for 30 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally); CHEMOTHERAPY ROOM APPOINTMENT: interferon alfa-2B SC injection for 30 minutes.
MULTIPLE DAY FOLLOW-UP (3)
DAY 17 AND 19 FOLLOW-UP; CHEMOTHERAPY ROOM APPOINTMENT: interferon alfa-2B SC injection for 30 minutes.
DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally); CHEMOTHERAPY ROOM APPOINTMENT: interferon alfa-2B SC injection for 30 minutes.
MULTIPLE DAY FOLLOW-UP (4)
DAY 24 AND 26 FOLLOW-UP; CHEMOTHERAPY ROOM APPOINTMENT: interferon alfa-2B SC injection for 30 minutes.
DAY 29 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally); CHEMOTHERAPY ROOM APPOINTMENT: interferon alfa-2B SC injection for 30 minutes.
Day 3, Cycle 1 – Planned for 6/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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-Medications
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Zztestonc,Jeff J [2507481]
6/15/2017 7:58:44 AM Page 2 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or
15mg/kg per dose for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 1 – Planned for 6/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 1 – Planned for 6/22/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or until disease progression.
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Jeff J [2507481]
6/15/2017 7:58:44 AM Page 3 of 49
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 WITHOUT DIFFERENTIAL
Expected-S+3 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+3 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+3 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 10, Cycle 1 – Planned for 6/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
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Zztestonc,Jeff J [2507481]
6/15/2017 7:58:44 AM Page 4 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 12, Cycle 1 – Planned for 6/26/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 1 – Planned for 6/29/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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+3 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+3 Approximate, Expires-S+365, Routine
CREATININE
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Zztestonc,Jeff J [2507481]
6/15/2017 7:58:44 AM Page 5 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Expected-S+3 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 17, Cycle 1 – Planned for 7/1/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 19, Cycle 1 – Planned for 7/3/2017
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Zztestonc,Jeff J [2507481]
6/15/2017 7:58:44 AM Page 6 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 1 – Planned for 7/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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+3 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+3 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+3 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Pre-Medications
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Zztestonc,Jeff J [2507481]
6/15/2017 7:58:44 AM Page 7 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or
15mg/kg per dose for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 24, Cycle 1 – Planned for 7/8/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 26, Cycle 1 – Planned for 7/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or until disease progression.
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Jeff J [2507481]
6/15/2017 7:58:44 AM Page 8 of 49
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-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 7/13/2017 through 8/9/2017 (28 days), Planned
Day 1, Cycle 2 – Planned for 7/13/2017
Treatment Plan Information
Reference Information (1)
RENAL CANCER: Quesada JR, et al. J Clin Oncol 1985;3:1522-8.
Reference Information (2)
RENAL CANCER: Muss HB, et al. J Clin Oncol 1987;5:286-91.
Reference Information (3)
RENAL CANCER: Flanigan RC, et al. N Engl J Med 2001;345:1655-9
Reference Information (4)
RENAL CANCER: Mickisch GHJ, et al. Lancet 2001;358:966-70.
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+3 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+3 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+3 Approximate, Expires-S+365, Routine
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Zztestonc,Jeff J [2507481]
6/15/2017 7:58:44 AM Page 9 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
MULTIPLE DAY FOLLOW-UP (1)
DAY 3 AND 5 FOLLOW-UP; CHEMOTHERAPY ROOM APPOINTMENT: interferon alfa-2B SC injection for 30 minutes.
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally); CHEMOTHERAPY ROOM APPOINTMENT: interferon alfa-2B SC injection for 30 minutes.
MULTIPLE DAY FOLLOW-UP (2)
DAY 10 AND 12 FOLLOW-UP; CHEMOTHERAPY ROOM APPOINTMENT: interferon alfa-2B SC injection for 30 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally); CHEMOTHERAPY ROOM APPOINTMENT: interferon alfa-2B SC injection for 30 minutes.
MULTIPLE DAY FOLLOW-UP (3)
DAY 17 AND 19 FOLLOW-UP; CHEMOTHERAPY ROOM APPOINTMENT: interferon alfa-2B SC injection for 30 minutes.
DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally); CHEMOTHERAPY ROOM APPOINTMENT: interferon alfa-2B SC injection for 30 minutes.
MULTIPLE DAY FOLLOW-UP (4)
DAY 24 AND 26 FOLLOW-UP; CHEMOTHERAPY ROOM APPOINTMENT: interferon alfa-2B SC injection for 30 minutes.
DAY 29 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally); CHEMOTHERAPY ROOM APPOINTMENT: interferon alfa-2B SC injection for 30 minutes.
Day 3, Cycle 2 – Planned for 7/15/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
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Zztestonc,Jeff J [2507481]
6/15/2017 7:58:44 AM Page 10 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 2 – Planned for 7/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 2 – Planned for 7/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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.
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Zztestonc,Jeff J [2507481]
6/15/2017 7:58:44 AM Page 11 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+3 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+3 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+3 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 10, Cycle 2 – Planned for 7/22/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
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Zztestonc,Jeff J [2507481]
6/15/2017 7:58:44 AM Page 12 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 12, Cycle 2 – Planned for 7/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 2 – Planned for 7/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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+3 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+3 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+3 Approximate, Expires-S+365, Routine
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Zztestonc,Jeff J [2507481]
6/15/2017 7:58:44 AM Page 13 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 17, Cycle 2 – Planned for 7/29/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 19, Cycle 2 – Planned for 7/31/2017
Treatment Plan Information
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Zztestonc,Jeff J [2507481]
6/15/2017 7:58:44 AM Page 14 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 2 – Planned for 8/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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+3 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+3 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+3 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Pre-Medications
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Zztestonc,Jeff J [2507481]
6/15/2017 7:58:44 AM Page 15 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or
15mg/kg per dose for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 24, Cycle 2 – Planned for 8/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 26, Cycle 2 – Planned for 8/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or until disease progression.
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Jeff J [2507481]
6/15/2017 7:58:44 AM Page 16 of 49
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-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 – 8/10/2017 through 9/6/2017 (28 days), Planned
Day 1, Cycle 3 – Planned for 8/10/2017
Treatment Plan Information
Reference Information (1)
RENAL CANCER: Quesada JR, et al. J Clin Oncol 1985;3:1522-8.
Reference Information (2)
RENAL CANCER: Muss HB, et al. J Clin Oncol 1987;5:286-91.
Reference Information (3)
RENAL CANCER: Flanigan RC, et al. N Engl J Med 2001;345:1655-9
Reference Information (4)
RENAL CANCER: Mickisch GHJ, et al. Lancet 2001;358:966-70.
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+3 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+3 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+3 Approximate, Expires-S+365, Routine
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Zztestonc,Jeff J [2507481]
6/15/2017 7:58:44 AM Page 17 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
MULTIPLE DAY FOLLOW-UP (1)
DAY 3 AND 5 FOLLOW-UP; CHEMOTHERAPY ROOM APPOINTMENT: interferon alfa-2B SC injection for 30 minutes.
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally); CHEMOTHERAPY ROOM APPOINTMENT: interferon alfa-2B SC injection for 30 minutes.
MULTIPLE DAY FOLLOW-UP (2)
DAY 10 AND 12 FOLLOW-UP; CHEMOTHERAPY ROOM APPOINTMENT: interferon alfa-2B SC injection for 30 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally); CHEMOTHERAPY ROOM APPOINTMENT: interferon alfa-2B SC injection for 30 minutes.
MULTIPLE DAY FOLLOW-UP (3)
DAY 17 AND 19 FOLLOW-UP; CHEMOTHERAPY ROOM APPOINTMENT: interferon alfa-2B SC injection for 30 minutes.
DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally); CHEMOTHERAPY ROOM APPOINTMENT: interferon alfa-2B SC injection for 30 minutes.
MULTIPLE DAY FOLLOW-UP (4)
DAY 24 AND 26 FOLLOW-UP; CHEMOTHERAPY ROOM APPOINTMENT: interferon alfa-2B SC injection for 30 minutes.
DAY 29 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally); CHEMOTHERAPY ROOM APPOINTMENT: interferon alfa-2B SC injection for 30 minutes.
Day 3, Cycle 3 – Planned for 8/12/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
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Zztestonc,Jeff J [2507481]
6/15/2017 7:58:44 AM Page 18 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 3 – Planned for 8/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 3 – Planned for 8/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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.
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Zztestonc,Jeff J [2507481]
6/15/2017 7:58:44 AM Page 19 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+3 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+3 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+3 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 10, Cycle 3 – Planned for 8/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
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Zztestonc,Jeff J [2507481]
6/15/2017 7:58:44 AM Page 20 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 12, Cycle 3 – Planned for 8/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 3 – Planned for 8/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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+3 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+3 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+3 Approximate, Expires-S+365, Routine
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Zztestonc,Jeff J [2507481]
6/15/2017 7:58:44 AM Page 21 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 17, Cycle 3 – Planned for 8/26/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 19, Cycle 3 – Planned for 8/28/2017
Treatment Plan Information
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Zztestonc,Jeff J [2507481]
6/15/2017 7:58:44 AM Page 22 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 3 – Planned for 8/31/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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+3 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+3 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+3 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Pre-Medications
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Zztestonc,Jeff J [2507481]
6/15/2017 7:58:44 AM Page 23 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or
15mg/kg per dose for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 24, Cycle 3 – Planned for 9/2/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 26, Cycle 3 – Planned for 9/4/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or until disease progression.
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Jeff J [2507481]
6/15/2017 7:58:44 AM Page 24 of 49
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-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 – 9/7/2017 through 10/4/2017 (28 days), Planned
Day 1, Cycle 4 – Planned for 9/7/2017
Treatment Plan Information
Reference Information (1)
RENAL CANCER: Quesada JR, et al. J Clin Oncol 1985;3:1522-8.
Reference Information (2)
RENAL CANCER: Muss HB, et al. J Clin Oncol 1987;5:286-91.
Reference Information (3)
RENAL CANCER: Flanigan RC, et al. N Engl J Med 2001;345:1655-9
Reference Information (4)
RENAL CANCER: Mickisch GHJ, et al. Lancet 2001;358:966-70.
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+3 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+3 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+3 Approximate, Expires-S+365, Routine
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Zztestonc,Jeff J [2507481]
6/15/2017 7:58:44 AM Page 25 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
MULTIPLE DAY FOLLOW-UP (1)
DAY 3 AND 5 FOLLOW-UP; CHEMOTHERAPY ROOM APPOINTMENT: interferon alfa-2B SC injection for 30 minutes.
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally); CHEMOTHERAPY ROOM APPOINTMENT: interferon alfa-2B SC injection for 30 minutes.
MULTIPLE DAY FOLLOW-UP (2)
DAY 10 AND 12 FOLLOW-UP; CHEMOTHERAPY ROOM APPOINTMENT: interferon alfa-2B SC injection for 30 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally); CHEMOTHERAPY ROOM APPOINTMENT: interferon alfa-2B SC injection for 30 minutes.
MULTIPLE DAY FOLLOW-UP (3)
DAY 17 AND 19 FOLLOW-UP; CHEMOTHERAPY ROOM APPOINTMENT: interferon alfa-2B SC injection for 30 minutes.
DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally); CHEMOTHERAPY ROOM APPOINTMENT: interferon alfa-2B SC injection for 30 minutes.
MULTIPLE DAY FOLLOW-UP (4)
DAY 24 AND 26 FOLLOW-UP; CHEMOTHERAPY ROOM APPOINTMENT: interferon alfa-2B SC injection for 30 minutes.
DAY 29 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally); CHEMOTHERAPY ROOM APPOINTMENT: interferon alfa-2B SC injection for 30 minutes.
Day 3, Cycle 4 – Planned for 9/9/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
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Zztestonc,Jeff J [2507481]
6/15/2017 7:58:44 AM Page 26 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 4 – Planned for 9/11/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 4 – Planned for 9/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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.
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Zztestonc,Jeff J [2507481]
6/15/2017 7:58:44 AM Page 27 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+3 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+3 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+3 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 10, Cycle 4 – Planned for 9/16/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
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Zztestonc,Jeff J [2507481]
6/15/2017 7:58:44 AM Page 28 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 12, Cycle 4 – Planned for 9/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 4 – Planned for 9/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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+3 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+3 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+3 Approximate, Expires-S+365, Routine
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Zztestonc,Jeff J [2507481]
6/15/2017 7:58:44 AM Page 29 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 17, Cycle 4 – Planned for 9/23/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 19, Cycle 4 – Planned for 9/25/2017
Treatment Plan Information
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Zztestonc,Jeff J [2507481]
6/15/2017 7:58:44 AM Page 30 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 4 – Planned for 9/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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+3 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+3 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+3 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Pre-Medications
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Zztestonc,Jeff J [2507481]
6/15/2017 7:58:44 AM Page 31 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or
15mg/kg per dose for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 24, Cycle 4 – Planned for 9/30/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 26, Cycle 4 – Planned for 10/2/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or until disease progression.
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Jeff J [2507481]
6/15/2017 7:58:44 AM Page 32 of 49
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-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 – 10/5/2017 through 11/1/2017 (28 days), Planned
Day 1, Cycle 5 – Planned for 10/5/2017
Treatment Plan Information
Reference Information (1)
RENAL CANCER: Quesada JR, et al. J Clin Oncol 1985;3:1522-8.
Reference Information (2)
RENAL CANCER: Muss HB, et al. J Clin Oncol 1987;5:286-91.
Reference Information (3)
RENAL CANCER: Flanigan RC, et al. N Engl J Med 2001;345:1655-9
Reference Information (4)
RENAL CANCER: Mickisch GHJ, et al. Lancet 2001;358:966-70.
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+3 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+3 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+3 Approximate, Expires-S+365, Routine
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Zztestonc,Jeff J [2507481]
6/15/2017 7:58:44 AM Page 33 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
MULTIPLE DAY FOLLOW-UP (1)
DAY 3 AND 5 FOLLOW-UP; CHEMOTHERAPY ROOM APPOINTMENT: interferon alfa-2B SC injection for 30 minutes.
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally); CHEMOTHERAPY ROOM APPOINTMENT: interferon alfa-2B SC injection for 30 minutes.
MULTIPLE DAY FOLLOW-UP (2)
DAY 10 AND 12 FOLLOW-UP; CHEMOTHERAPY ROOM APPOINTMENT: interferon alfa-2B SC injection for 30 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally); CHEMOTHERAPY ROOM APPOINTMENT: interferon alfa-2B SC injection for 30 minutes.
MULTIPLE DAY FOLLOW-UP (3)
DAY 17 AND 19 FOLLOW-UP; CHEMOTHERAPY ROOM APPOINTMENT: interferon alfa-2B SC injection for 30 minutes.
DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally); CHEMOTHERAPY ROOM APPOINTMENT: interferon alfa-2B SC injection for 30 minutes.
MULTIPLE DAY FOLLOW-UP (4)
DAY 24 AND 26 FOLLOW-UP; CHEMOTHERAPY ROOM APPOINTMENT: interferon alfa-2B SC injection for 30 minutes.
DAY 29 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally); CHEMOTHERAPY ROOM APPOINTMENT: interferon alfa-2B SC injection for 30 minutes.
Day 3, Cycle 5 – Planned for 10/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
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Zztestonc,Jeff J [2507481]
6/15/2017 7:58:44 AM Page 34 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 5 – Planned for 10/9/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 5 – Planned for 10/12/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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.
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Zztestonc,Jeff J [2507481]
6/15/2017 7:58:44 AM Page 35 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+3 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+3 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+3 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 10, Cycle 5 – Planned for 10/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
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Zztestonc,Jeff J [2507481]
6/15/2017 7:58:44 AM Page 36 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 12, Cycle 5 – Planned for 10/16/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 5 – Planned for 10/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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+3 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+3 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+3 Approximate, Expires-S+365, Routine
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Zztestonc,Jeff J [2507481]
6/15/2017 7:58:44 AM Page 37 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 17, Cycle 5 – Planned for 10/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 19, Cycle 5 – Planned for 10/23/2017
Treatment Plan Information
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Zztestonc,Jeff J [2507481]
6/15/2017 7:58:44 AM Page 38 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 5 – Planned for 10/26/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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+3 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+3 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+3 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Pre-Medications
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Zztestonc,Jeff J [2507481]
6/15/2017 7:58:44 AM Page 39 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or
15mg/kg per dose for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 24, Cycle 5 – Planned for 10/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 26, Cycle 5 – Planned for 10/30/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or until disease progression.
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Jeff J [2507481]
6/15/2017 7:58:44 AM Page 40 of 49
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-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 6 – 11/2/2017 through 11/29/2017 (28 days), Planned
Day 1, Cycle 6 – Planned for 11/2/2017
Treatment Plan Information
Reference Information (1)
RENAL CANCER: Quesada JR, et al. J Clin Oncol 1985;3:1522-8.
Reference Information (2)
RENAL CANCER: Muss HB, et al. J Clin Oncol 1987;5:286-91.
Reference Information (3)
RENAL CANCER: Flanigan RC, et al. N Engl J Med 2001;345:1655-9
Reference Information (4)
RENAL CANCER: Mickisch GHJ, et al. Lancet 2001;358:966-70.
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+3 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+3 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+3 Approximate, Expires-S+365, Routine
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Zztestonc,Jeff J [2507481]
6/15/2017 7:58:44 AM Page 41 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
MULTIPLE DAY FOLLOW-UP (1)
DAY 3 AND 5 FOLLOW-UP; CHEMOTHERAPY ROOM APPOINTMENT: interferon alfa-2B SC injection for 30 minutes.
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally); CHEMOTHERAPY ROOM APPOINTMENT: interferon alfa-2B SC injection for 30 minutes.
MULTIPLE DAY FOLLOW-UP (2)
DAY 10 AND 12 FOLLOW-UP; CHEMOTHERAPY ROOM APPOINTMENT: interferon alfa-2B SC injection for 30 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally); CHEMOTHERAPY ROOM APPOINTMENT: interferon alfa-2B SC injection for 30 minutes.
MULTIPLE DAY FOLLOW-UP (3)
DAY 17 AND 19 FOLLOW-UP; CHEMOTHERAPY ROOM APPOINTMENT: interferon alfa-2B SC injection for 30 minutes.
DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally); CHEMOTHERAPY ROOM APPOINTMENT: interferon alfa-2B SC injection for 30 minutes.
MULTIPLE DAY FOLLOW-UP (4)
DAY 24 AND 26 FOLLOW-UP; CHEMOTHERAPY ROOM APPOINTMENT: interferon alfa-2B SC injection for 30 minutes.
DAY 29 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally); CHEMOTHERAPY ROOM APPOINTMENT: interferon alfa-2B SC injection for 30 minutes.
Day 3, Cycle 6 – Planned for 11/4/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
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Zztestonc,Jeff J [2507481]
6/15/2017 7:58:44 AM Page 42 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 6 – Planned for 11/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 6 – Planned for 11/9/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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.
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Zztestonc,Jeff J [2507481]
6/15/2017 7:58:44 AM Page 43 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+3 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+3 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+3 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 10, Cycle 6 – Planned for 11/11/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
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Zztestonc,Jeff J [2507481]
6/15/2017 7:58:44 AM Page 44 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 12, Cycle 6 – Planned for 11/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 6 – Planned for 11/16/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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+3 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+3 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+3 Approximate, Expires-S+365, Routine
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Zztestonc,Jeff J [2507481]
6/15/2017 7:58:44 AM Page 45 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 17, Cycle 6 – Planned for 11/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 19, Cycle 6 – Planned for 11/20/2017
Treatment Plan Information
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Zztestonc,Jeff J [2507481]
6/15/2017 7:58:44 AM Page 46 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 6 – Planned for 11/23/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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+3 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+3 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+3 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL.
Pre-Medications
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Zztestonc,Jeff J [2507481]
6/15/2017 7:58:44 AM Page 47 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or
15mg/kg per dose for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 24, Cycle 6 – Planned for 11/25/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or 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-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 26, Cycle 6 – Planned for 11/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cancer (Adjuvant/Advanced); THERAPY: interferon alfa-2B 5 to 10 million units/m2 subcutaneous 3 times per
week; CYCLE LENGTH: 28 days; COURSE: 6 cycles or until disease progression.
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Jeff J [2507481]
6/15/2017 7:58:44 AM Page 48 of 49
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-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 20 Million Units
20 Million Units (rounded from 19.6 Million Units = 10 Million Units/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,Jeff J [2507481]
6/15/2017 7:58:44 AM Page 49 of 49
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org