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/clinical/cckm-tools/content/beacon-protocols/head-and-neck/name-111335-en.cckm

201711317

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Beacon Protocols,Head and Neck

CSC HEAD NECK Nivolumab(28D:1,15) VER 11-10-17 (HL 5982)

CSC HEAD NECK Nivolumab(28D:1,15) VER 11-10-17 (HL 5982) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Head and Neck


CSC HEAD/NECK NIVOLUMAB(28D:1,15) VER: 11/10/17 –  Properties
Pre-Cycle –  11/6/2017 through 11/12/2017 (7 days), Planned
Day 1, Pre-Cycle –  Planned for 11/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Squamous Cell Carcinoma of the Head and Neck; THERAPY: nivolumab 3 mg/kg IV Day 1 and 15; CYCLE
LENGTH: 28 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S Approximate, Expires: S+397, Routine
GLUCOSE
Expected: S Approximate, Expires: S+397, Routine
BUN
Expected: S Approximate, Expires: S+397, Routine
CREATININE
Expected: S Approximate, Expires: S+397, Routine
CALCIUM
Expected: S Approximate, Expires: S+397, Routine
ALBUMIN
Expected: S Approximate, Expires: S+397, Routine
PROTEIN, TOTAL
Expected: S Approximate, Expires: S+397, Routine
BILIRUBIN, TOTAL
Expected: S Approximate, Expires: S+397, Routine
AST/SGOT
Expected: S Approximate, Expires: S+397, Routine
ALT/SGPT
Expected: S Approximate, Expires: S+397, Routine
ALKALINE PHOSPHATASE
Expected: S Approximate, Expires: S+397, Routine
TSH
Expected: S Approximate, Expires: S+365, Routine
T4, FREE
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Zztestonc,PedsBeiber [2668824]
11/13/2017 10:54:04 AM Page 1 of 27
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

Expected: S Approximate, Expires: S+365, Routine
LIPASE
Expected: S Approximate, Expires: S+365, Routine
AMYLASE
Expected: S Approximate, Expires: S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected: S Approximate, Expires: S+122, Routine
Take Home Medications
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed for nausea/vomiting., 8 mg, Disp-30 tab, R-5, EVERY 8 HOURS PRN
starting S, Local Printer
prochlorperazine (COMPAZINE) 10 MG tab
Take 1 tab by mouth every 6 hours as needed for nausea/vomiting., 10 mg, Disp-30 tab, R-5, EVERY 6 HOURS PRN
starting S, Local Printer
Cycle 1 –  11/13/2017 through 12/10/2017 (28 days), Planned
Day 1, Cycle 1 –  Planned for 11/13/2017
Treatment Plan Information
Reference Information (1)
SQUAMOUS CELL CARCINOMA OF THE HEAD AND NECK: Ferris RL, et al. N Engl J Med 2016;375(19):1856-67.
Treatment Plan Summary
DISEASE: Squamous Cell Carcinoma of the Head and Neck; THERAPY: nivolumab 3 mg/kg IV Day 1 and 15; CYCLE
LENGTH: 28 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, ALT, Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to
100K/µL or Creatinine greater than 1.5 X ULN or AST greater than 2.5 X ULN (greater than 5 X ULN if known liver
metastasis) or ALT greater than 2.5 X ULN (greater than 5 X ULN if known liver metastasis) or Total Bilirubin greater than
1.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
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Zztestonc,PedsBeiber [2668824]
11/13/2017 10:54:04 AM Page 2 of 27
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Hypersensitivity reaction to nivolumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Patient Instructions(1)
Advise patients to contact provider right away with signs of pneumonitis (new or worse cough, chest pain or shortness
of breath) or colitis (abdominal pain; mucus or blood in stool).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 15 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
nivolumab (OPDIVO) 3 mg/kg in sodium chloride 0.9 % 100 mL bag
3 mg/kg, Intravenous, ONCE, 1 dose Starting when released, Administer over 30 Minutes
Administer with low protein binding 0.2 or 0.22 micron filter over 30 minutes. Do not shake. Do not co-administer other
drugs through same infusion line. Hypersensitivity reaction to nivolumab can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See Emergency Medications
Follow-Up
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein,
Total Bilirubin, AST, ALT, Alkaline Phosphatase, Lipase, Amylase; CHEMOTHERAPY ROOM APPOINTMENT: nivolumab for
60 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase,
Lipase, Amylase; LABS (prior to every EVEN Cycle only): TSH and Free T4; CHEMOTHERAPY ROOM APPOINTMENT:
nivolumab for 60 minutes.
Day 15, Cycle 1 –  Planned for 11/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Squamous Cell Carcinoma of the Head and Neck; THERAPY: nivolumab 3 mg/kg IV Day 1 and 15; CYCLE
LENGTH: 28 days; COURSE: until disease progression.
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Zztestonc,PedsBeiber [2668824]
11/13/2017 10:54:04 AM Page 3 of 27
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

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+14 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
GLUCOSE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
BUN
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
CALCIUM
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALBUMIN
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
PROTEIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
LIPASE
Expected: S+14 Approximate, Expires: S+365, Routine
AMYLASE
Expected: S+14 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, ALT, Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to
100K/µL or Creatinine greater than 1.5 X ULN or AST greater than 2.5 X ULN (greater than 5 X ULN if known liver
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Zztestonc,PedsBeiber [2668824]
11/13/2017 10:54:04 AM Page 4 of 27
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

metastasis) or ALT greater than 2.5 X ULN (greater than 5 X ULN if known liver metastasis) or Total Bilirubin greater than
1.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to nivolumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Patient Instructions(1)
Advise patients to contact provider right away with signs of pneumonitis (new or worse cough, chest pain or shortness
of breath) or colitis (abdominal pain; mucus or blood in stool).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 15 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
nivolumab (OPDIVO) 3 mg/kg in sodium chloride 0.9 % 100 mL bag
3 mg/kg, Intravenous, ONCE, 1 dose Starting when released, Administer over 30 Minutes
Administer with low protein binding 0.2 or 0.22 micron filter over 30 minutes. Do not shake. Do not co-administer other
drugs through same infusion line. Hypersensitivity reaction to nivolumab can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See Emergency Medications
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 –  12/11/2017 through 1/7/2018 (28 days), Planned
Day 1, Cycle 2 –  Planned for 12/11/2017
Treatment Plan Information
Treatment Plan Summary
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Zztestonc,PedsBeiber [2668824]
11/13/2017 10:54:04 AM Page 5 of 27
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

DISEASE: Squamous Cell Carcinoma of the Head and Neck; THERAPY: nivolumab 3 mg/kg IV Day 1 and 15; CYCLE
LENGTH: 28 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
GLUCOSE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
BUN
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
CALCIUM
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALBUMIN
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
PROTEIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
LIPASE
Expected: S+14 Approximate, Expires: S+365, Routine
AMYLASE
Expected: S+14 Approximate, Expires: S+365, Routine
Pre-Labs (delete all that do not apply)
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Zztestonc,PedsBeiber [2668824]
11/13/2017 10:54:04 AM Page 6 of 27
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

TSH
Expected: S+14 Approximate, Expires: S+365, Routine
Baseline and prior to every EVEN Cycle only.
T4, FREE
Expected: S+14 Approximate, Expires: S+365, Routine
Baseline and prior to every EVEN Cycle only.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, ALT, Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to
100K/µL or Creatinine greater than 1.5 X ULN or AST greater than 2.5 X ULN (greater than 5 X ULN if known liver
metastasis) or ALT greater than 2.5 X ULN (greater than 5 X ULN if known liver metastasis) or Total Bilirubin greater than
1.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to nivolumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Patient Instructions(1)
Advise patients to contact provider right away with signs of pneumonitis (new or worse cough, chest pain or shortness
of breath) or colitis (abdominal pain; mucus or blood in stool).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 15 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
nivolumab (OPDIVO) 3 mg/kg in sodium chloride 0.9 % 100 mL bag
3 mg/kg, Intravenous, ONCE, 1 dose Starting when released, Administer over 30 Minutes
Administer with low protein binding 0.2 or 0.22 micron filter over 30 minutes. Do not shake. Do not co-administer other
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Zztestonc,PedsBeiber [2668824]
11/13/2017 10:54:04 AM Page 7 of 27
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

drugs through same infusion line. Hypersensitivity reaction to nivolumab can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See Emergency Medications
Follow-Up
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein,
Total Bilirubin, AST, ALT, Alkaline Phosphatase, Lipase, Amylase; CHEMOTHERAPY ROOM APPOINTMENT: nivolumab for
60 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase,
Lipase, Amylase; LABS (prior to every EVEN Cycle only): TSH and Free T4; CHEMOTHERAPY ROOM APPOINTMENT:
nivolumab for 60 minutes.
Day 15, Cycle 2 –  Planned for 12/25/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Squamous Cell Carcinoma of the Head and Neck; THERAPY: nivolumab 3 mg/kg IV Day 1 and 15; CYCLE
LENGTH: 28 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
GLUCOSE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
BUN
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
CALCIUM
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALBUMIN
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
PROTEIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
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Zztestonc,PedsBeiber [2668824]
11/13/2017 10:54:04 AM Page 8 of 27
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
LIPASE
Expected: S+14 Approximate, Expires: S+365, Routine
AMYLASE
Expected: S+14 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, ALT, Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to
100K/µL or Creatinine greater than 1.5 X ULN or AST greater than 2.5 X ULN (greater than 5 X ULN if known liver
metastasis) or ALT greater than 2.5 X ULN (greater than 5 X ULN if known liver metastasis) or Total Bilirubin greater than
1.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to nivolumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Patient Instructions(1)
Advise patients to contact provider right away with signs of pneumonitis (new or worse cough, chest pain or shortness
of breath) or colitis (abdominal pain; mucus or blood in stool).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 15 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
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Zztestonc,PedsBeiber [2668824]
11/13/2017 10:54:04 AM Page 9 of 27
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Treatment Medications
nivolumab (OPDIVO) 3 mg/kg in sodium chloride 0.9 % 100 mL bag
3 mg/kg, Intravenous, ONCE, 1 dose Starting when released, Administer over 30 Minutes
Administer with low protein binding 0.2 or 0.22 micron filter over 30 minutes. Do not shake. Do not co-administer other
drugs through same infusion line. Hypersensitivity reaction to nivolumab can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See Emergency Medications
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 –  1/8/2018 through 2/4/2018 (28 days), Planned
Day 1, Cycle 3 –  Planned for 1/8/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Squamous Cell Carcinoma of the Head and Neck; THERAPY: nivolumab 3 mg/kg IV Day 1 and 15; CYCLE
LENGTH: 28 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
GLUCOSE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
BUN
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
CALCIUM
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALBUMIN
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
PROTEIN, TOTAL
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Zztestonc,PedsBeiber [2668824]
11/13/2017 10:54:04 AM Page 10 of 27
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Expected: S+14 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
LIPASE
Expected: S+14 Approximate, Expires: S+365, Routine
AMYLASE
Expected: S+14 Approximate, Expires: S+365, Routine
Pre-Labs (delete all that do not apply)
TSH
Expected: S+14 Approximate, Expires: S+365, Routine
Baseline and prior to every EVEN Cycle only.
T4, FREE
Expected: S+14 Approximate, Expires: S+365, Routine
Baseline and prior to every EVEN Cycle only.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, ALT, Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to
100K/µL or Creatinine greater than 1.5 X ULN or AST greater than 2.5 X ULN (greater than 5 X ULN if known liver
metastasis) or ALT greater than 2.5 X ULN (greater than 5 X ULN if known liver metastasis) or Total Bilirubin greater than
1.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to nivolumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Patient Instructions(1)
Advise patients to contact provider right away with signs of pneumonitis (new or worse cough, chest pain or shortness
of breath) or colitis (abdominal pain; mucus or blood in stool).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
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Zztestonc,PedsBeiber [2668824]
11/13/2017 10:54:04 AM Page 11 of 27
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 15 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
nivolumab (OPDIVO) 3 mg/kg in sodium chloride 0.9 % 100 mL bag
3 mg/kg, Intravenous, ONCE, 1 dose Starting when released, Administer over 30 Minutes
Administer with low protein binding 0.2 or 0.22 micron filter over 30 minutes. Do not shake. Do not co-administer other
drugs through same infusion line. Hypersensitivity reaction to nivolumab can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See Emergency Medications
Follow-Up
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein,
Total Bilirubin, AST, ALT, Alkaline Phosphatase, Lipase, Amylase; CHEMOTHERAPY ROOM APPOINTMENT: nivolumab for
60 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase,
Lipase, Amylase; LABS (prior to every EVEN Cycle only): TSH and Free T4; CHEMOTHERAPY ROOM APPOINTMENT:
nivolumab for 60 minutes.
Day 15, Cycle 3 –  Planned for 1/22/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Squamous Cell Carcinoma of the Head and Neck; THERAPY: nivolumab 3 mg/kg IV Day 1 and 15; CYCLE
LENGTH: 28 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
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Zztestonc,PedsBeiber [2668824]
11/13/2017 10:54:04 AM Page 12 of 27
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

GLUCOSE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
BUN
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
CALCIUM
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALBUMIN
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
PROTEIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
LIPASE
Expected: S+14 Approximate, Expires: S+365, Routine
AMYLASE
Expected: S+14 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, ALT, Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to
100K/µL or Creatinine greater than 1.5 X ULN or AST greater than 2.5 X ULN (greater than 5 X ULN if known liver
metastasis) or ALT greater than 2.5 X ULN (greater than 5 X ULN if known liver metastasis) or Total Bilirubin greater than
1.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to nivolumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Patient Instructions(1)
Advise patients to contact provider right away with signs of pneumonitis (new or worse cough, chest pain or shortness
of breath) or colitis (abdominal pain; mucus or blood in stool).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
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Zztestonc,PedsBeiber [2668824]
11/13/2017 10:54:04 AM Page 13 of 27
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 15 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
nivolumab (OPDIVO) 3 mg/kg in sodium chloride 0.9 % 100 mL bag
3 mg/kg, Intravenous, ONCE, 1 dose Starting when released, Administer over 30 Minutes
Administer with low protein binding 0.2 or 0.22 micron filter over 30 minutes. Do not shake. Do not co-administer other
drugs through same infusion line. Hypersensitivity reaction to nivolumab can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See Emergency Medications
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 –  2/5/2018 through 3/4/2018 (28 days), Planned
Day 1, Cycle 4 –  Planned for 2/5/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Squamous Cell Carcinoma of the Head and Neck; THERAPY: nivolumab 3 mg/kg IV Day 1 and 15; CYCLE
LENGTH: 28 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
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Zztestonc,PedsBeiber [2668824]
11/13/2017 10:54:04 AM Page 14 of 27
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
GLUCOSE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
BUN
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
CALCIUM
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALBUMIN
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
PROTEIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
LIPASE
Expected: S+14 Approximate, Expires: S+365, Routine
AMYLASE
Expected: S+14 Approximate, Expires: S+365, Routine
Pre-Labs (delete all that do not apply)
TSH
Expected: S+14 Approximate, Expires: S+365, Routine
Baseline and prior to every EVEN Cycle only.
T4, FREE
Expected: S+14 Approximate, Expires: S+365, Routine
Baseline and prior to every EVEN Cycle only.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, ALT, Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to
100K/µL or Creatinine greater than 1.5 X ULN or AST greater than 2.5 X ULN (greater than 5 X ULN if known liver
metastasis) or ALT greater than 2.5 X ULN (greater than 5 X ULN if known liver metastasis) or Total Bilirubin greater than
1.5 X ULN.
Nursing Procedure, Assessment and Monitoring
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Zztestonc,PedsBeiber [2668824]
11/13/2017 10:54:04 AM Page 15 of 27
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Hypersensitivity Monitoring (1)
Hypersensitivity reaction to nivolumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Patient Instructions(1)
Advise patients to contact provider right away with signs of pneumonitis (new or worse cough, chest pain or shortness
of breath) or colitis (abdominal pain; mucus or blood in stool).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 15 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
nivolumab (OPDIVO) 3 mg/kg in sodium chloride 0.9 % 100 mL bag
3 mg/kg, Intravenous, ONCE, 1 dose Starting when released, Administer over 30 Minutes
Administer with low protein binding 0.2 or 0.22 micron filter over 30 minutes. Do not shake. Do not co-administer other
drugs through same infusion line. Hypersensitivity reaction to nivolumab can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See Emergency Medications
Follow-Up
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein,
Total Bilirubin, AST, ALT, Alkaline Phosphatase, Lipase, Amylase; CHEMOTHERAPY ROOM APPOINTMENT: nivolumab for
60 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase,
Lipase, Amylase; LABS (prior to every EVEN Cycle only): TSH and Free T4; CHEMOTHERAPY ROOM APPOINTMENT:
nivolumab for 60 minutes.
Day 15, Cycle 4 –  Planned for 2/19/2018
Treatment Plan Information
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Zztestonc,PedsBeiber [2668824]
11/13/2017 10:54:04 AM Page 16 of 27
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Squamous Cell Carcinoma of the Head and Neck; THERAPY: nivolumab 3 mg/kg IV Day 1 and
15; CYCLE LENGTH: 28 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
GLUCOSE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
BUN
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
CALCIUM
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALBUMIN
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
PROTEIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
LIPASE
Expected: S+14 Approximate, Expires: S+365, Routine
AMYLASE
Expected: S+14 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, ALT, Total Bilirubin.
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Zztestonc,PedsBeiber [2668824]
11/13/2017 10:54:04 AM Page 17 of 27
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less
than or equal to 100K/µL or Creatinine greater than 1.5 X ULN or AST greater than 2.5 X ULN (greater
than 5 X ULN if known liver metastasis) or ALT greater than 2.5 X ULN (greater than 5 X ULN if known
liver metastasis) or Total Bilirubin greater than 1.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to nivolumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Patient Instructions(1)
Advise patients to contact provider right away with signs of pneumonitis (new or worse cough, chest pain or shortness
of breath) or colitis (abdominal pain; mucus or blood in stool).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 15 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
nivolumab (OPDIVO) 3 mg/kg in sodium chloride 0.9 % 100 mL bag
3 mg/kg, Intravenous, ONCE, 1 dose Starting when released, Administer over 30 Minutes
Administer with low protein binding 0.2 or 0.22 micron filter over 30 minutes. Do not shake. Do not co-administer other
drugs through same infusion line. Hypersensitivity reaction to nivolumab can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See Emergency Medications
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 –  3/5/2018 through 4/1/2018 (28 days), Planned
Day 1, Cycle 5 –  Planned for 3/5/2018
Treatment Plan Information
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Zztestonc,PedsBeiber [2668824]
11/13/2017 10:54:04 AM Page 18 of 27
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Squamous Cell Carcinoma of the Head and Neck; THERAPY: nivolumab 3 mg/kg IV Day 1 and 15; CYCLE
LENGTH: 28 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
GLUCOSE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
BUN
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
CALCIUM
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALBUMIN
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
PROTEIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
LIPASE
Expected: S+14 Approximate, Expires: S+365, Routine
AMYLASE
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Zztestonc,PedsBeiber [2668824]
11/13/2017 10:54:04 AM Page 19 of 27
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Expected: S+14 Approximate, Expires: S+365, Routine
Pre-Labs (delete all that do not apply)
TSH
Expected: S+14 Approximate, Expires: S+365, Routine
Baseline and prior to every EVEN Cycle only.
T4, FREE
Expected: S+14 Approximate, Expires: S+365, Routine
Baseline and prior to every EVEN Cycle only.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, ALT, Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to
100K/µL or Creatinine greater than 1.5 X ULN or AST greater than 2.5 X ULN (greater than 5 X ULN if known liver
metastasis) or ALT greater than 2.5 X ULN (greater than 5 X ULN if known liver metastasis) or Total Bilirubin greater than
1.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to nivolumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Patient Instructions(1)
Advise patients to contact provider right away with signs of pneumonitis (new or worse cough, chest pain or shortness
of breath) or colitis (abdominal pain; mucus or blood in stool).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 15 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
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Zztestonc,PedsBeiber [2668824]
11/13/2017 10:54:04 AM Page 20 of 27
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

nivolumab (OPDIVO) 3 mg/kg in sodium chloride 0.9 % 100 mL bag
3 mg/kg, Intravenous, ONCE, 1 dose Starting when released, Administer over 30 Minutes
Administer with low protein binding 0.2 or 0.22 micron filter over 30 minutes. Do not shake. Do not co-
administer other drugs through same infusion line. Hypersensitivity reaction to nivolumab can occur.
For first and second dose, patient should be treated in a location to optimize emergency care. See
Emergency Medications
Follow-Up
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein,
Total Bilirubin, AST, ALT, Alkaline Phosphatase, Lipase, Amylase; CHEMOTHERAPY ROOM APPOINTMENT: nivolumab for
60 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase,
Lipase, Amylase; LABS (prior to every EVEN Cycle only): TSH and Free T4; CHEMOTHERAPY ROOM APPOINTMENT:
nivolumab for 60 minutes.
Day 15, Cycle 5 –  Planned for 3/19/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Squamous Cell Carcinoma of the Head and Neck; THERAPY: nivolumab 3 mg/kg IV Day 1 and 15; CYCLE
LENGTH: 28 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
GLUCOSE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
BUN
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
CALCIUM
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALBUMIN
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
PROTEIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
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Zztestonc,PedsBeiber [2668824]
11/13/2017 10:54:04 AM Page 21 of 27
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

BILIRUBIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
LIPASE
Expected: S+14 Approximate, Expires: S+365, Routine
AMYLASE
Expected: S+14 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, ALT, Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to
100K/µL or Creatinine greater than 1.5 X ULN or AST greater than 2.5 X ULN (greater than 5 X ULN if known liver
metastasis) or ALT greater than 2.5 X ULN (greater than 5 X ULN if known liver metastasis) or Total Bilirubin greater than
1.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to nivolumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Patient Instructions(1)
Advise patients to contact provider right away with signs of pneumonitis (new or worse cough, chest pain or shortness
of breath) or colitis (abdominal pain; mucus or blood in stool).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 15 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
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Zztestonc,PedsBeiber [2668824]
11/13/2017 10:54:04 AM Page 22 of 27
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
nivolumab (OPDIVO) 3 mg/kg in sodium chloride 0.9 % 100 mL bag
3 mg/kg, Intravenous, ONCE, 1 dose Starting when released, Administer over 30 Minutes
Administer with low protein binding 0.2 or 0.22 micron filter over 30 minutes. Do not shake. Do not co-administer other
drugs through same infusion line. Hypersensitivity reaction to nivolumab can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See Emergency Medications
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 6 –  4/2/2018 through 4/29/2018 (28 days), Planned
Day 1, Cycle 6 –  Planned for 4/2/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Squamous Cell Carcinoma of the Head and Neck; THERAPY: nivolumab 3 mg/kg IV Day 1 and 15; CYCLE
LENGTH: 28 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
GLUCOSE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
BUN
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
CALCIUM
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
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Zztestonc,PedsBeiber [2668824]
11/13/2017 10:54:04 AM Page 23 of 27
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

ALBUMIN
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
PROTEIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
LIPASE
Expected: S+14 Approximate, Expires: S+365, Routine
AMYLASE
Expected: S+14 Approximate, Expires: S+365, Routine
Pre-Labs (delete all that do not apply)
TSH
Expected: S+14 Approximate, Expires: S+365, Routine
Baseline and prior to every EVEN Cycle only.
T4, FREE
Expected: S+14 Approximate, Expires: S+365, Routine
Baseline and prior to every EVEN Cycle only.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, ALT, Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to
100K/µL or Creatinine greater than 1.5 X ULN or AST greater than 2.5 X ULN (greater than 5 X ULN if known liver
metastasis) or ALT greater than 2.5 X ULN (greater than 5 X ULN if known liver metastasis) or Total Bilirubin greater than
1.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to nivolumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Patient Instructions(1)
Advise patients to contact provider right away with signs of pneumonitis (new or worse cough, chest pain or shortness
of breath) or colitis (abdominal pain; mucus or blood in stool).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
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Zztestonc,PedsBeiber [2668824]
11/13/2017 10:54:04 AM Page 24 of 27
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 15 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
nivolumab (OPDIVO) 3 mg/kg in sodium chloride 0.9 % 100 mL bag
3 mg/kg, Intravenous, ONCE, 1 dose Starting when released, Administer over 30 Minutes
Administer with low protein binding 0.2 or 0.22 micron filter over 30 minutes. Do not shake. Do not co-administer other
drugs through same infusion line. Hypersensitivity reaction to nivolumab can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See Emergency Medications
Follow-Up
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein,
Total Bilirubin, AST, ALT, Alkaline Phosphatase, Lipase, Amylase; CHEMOTHERAPY ROOM APPOINTMENT: nivolumab for
60 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase,
Lipase, Amylase; LABS (prior to every EVEN Cycle only): TSH and Free T4; CHEMOTHERAPY ROOM APPOINTMENT:
nivolumab for 60 minutes.
Day 15, Cycle 6 –  Planned for 4/16/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Squamous Cell Carcinoma of the Head and Neck; THERAPY: nivolumab 3 mg/kg IV Day 1 and 15; CYCLE
LENGTH: 28 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Routine
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Zztestonc,PedsBeiber [2668824]
11/13/2017 10:54:04 AM Page 25 of 27
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

ELECTROLYTES
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
GLUCOSE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
BUN
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
CALCIUM
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALBUMIN
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
PROTEIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
LIPASE
Expected: S+14 Approximate, Expires: S+365, Routine
AMYLASE
Expected: S+14 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, ALT, Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to
100K/µL or Creatinine greater than 1.5 X ULN or AST greater than 2.5 X ULN (greater than 5 X ULN if known liver
metastasis) or ALT greater than 2.5 X ULN (greater than 5 X ULN if known liver metastasis) or Total Bilirubin greater than
1.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to nivolumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Patient Instructions(1)
Advise patients to contact provider right away with signs of pneumonitis (new or worse cough, chest pain or shortness
of breath) or colitis (abdominal pain; mucus or blood in stool).
Flush Venous Access Device per Guidelines
Order details
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Zztestonc,PedsBeiber [2668824]
11/13/2017 10:54:04 AM Page 26 of 27
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 15 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
nivolumab (OPDIVO) 3 mg/kg in sodium chloride 0.9 % 100 mL bag
3 mg/kg, Intravenous, ONCE, 1 dose Starting when released, Administer over 30 Minutes
Administer with low protein binding 0.2 or 0.22 micron filter over 30 minutes. Do not shake. Do not co-administer other
drugs through same infusion line. Hypersensitivity reaction to nivolumab can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See Emergency Medications
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,PedsBeiber [2668824]
11/13/2017 10:54:04 AM Page 27 of 27
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org