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/clinical/cckm-tools/content/beacon-protocols/head-and-neck/name-111336-en.cckm

201711317

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UWHC,UWMF,

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

CSC Head-Neck Pembrolizumab(21D:1) Ver 11-10-17 (HL 6154)

CSC Head-Neck Pembrolizumab(21D:1) Ver 11-10-17 (HL 6154) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Head and Neck


CSC HEAD/NECK PEMBROLIZUMAB(21D:1) 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: Head and Neck Squamous Cell Carcinoma (Advanced); THERAPY: pembrolizumab 200 mg IV Day 1; CYCLE
LENGTH: 21 days; COURSE: until disease progression or maximum 24 months in patients without disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S Approximate, Expires: S+397, Routine
GLUCOSE
Expected: S Approximate, Expires: S+397, Routine
BUN
Expected: S Approximate, Expires: S+397, Routine
CREATININE
Expected: S Approximate, Expires: S+397, Routine
CALCIUM
Expected: S Approximate, Expires: S+397, Routine
ALBUMIN
Expected: S Approximate, Expires: S+397, Routine
PROTEIN, TOTAL
Expected: S Approximate, Expires: S+397, Routine
BILIRUBIN, TOTAL
Expected: S Approximate, Expires: S+397, Routine
AST/SGOT
Expected: S Approximate, Expires: S+397, Routine
ALT/SGPT
Expected: S Approximate, Expires: S+397, Routine
ALKALINE PHOSPHATASE
Expected: S Approximate, Expires: S+397, Routine
LIPASE
Expected: S Approximate, Expires: S+365, Routine
AMYLASE
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Zztestonc,PedsBeiber [2668824]
11/13/2017 10:56:23 AM Page 1 of 16
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
TSH
Expected: S Approximate, Expires: S+365, Routine
Baseline and prior to every EVEN Cycle only.
T4, FREE
Expected: S Approximate, Expires: S+365, Routine
Baseline and prior to every EVEN Cycle only.
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 12/3/2017 (21 days), Planned
Day 1, Cycle 1 –  Planned for 11/13/2017
Treatment Plan Information
Reference Information (1)
HEAD AND NECK SQUAMOUS CELL CARCINOMA: Seiwert TY, et al. Lancet Oncol 2016;17(7):956-65.
Reference Information (2)
HEAD AND NECK SQUAMOUS CELL CARCINOMA: Chow LQM, et al. J Clin Onc 2016;34(32):3838-45.
Treatment Plan Summary
DISEASE: Head and Neck Squamous Cell Carcinoma (Advanced); THERAPY: pembrolizumab 200 mg IV Day 1; CYCLE
LENGTH: 21 days; COURSE: until disease progression or maximum 24 months in patients without 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 and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to 100K/µL
or Creatinine greater than 1.5 X ULN or AST greater than 2.5 X ULN (or greater than 5 X ULN if known liver metastases)
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Zztestonc,PedsBeiber [2668824]
11/13/2017 10:56:23 AM Page 2 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

or ALT greater than 2.5 X ULN (or greater than 5 X ULN if known liver metastases) or Total Bilirubin greater than 1.5 X
ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to pembrolizumab can occur. For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications. Patient must be monitored for 30 minutes after first dose of
pembrolizumab.
Monitoring Parameters (1)
Notify MD for Systolic Blood Pressure below 100 mmHg (if below pre-infusion Blood Pressure) or for any symptoms of
hypotension.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor Blood Pressure, Heart Rate, Temperature, Respiratory Rate and Pain Level every 15 minutes during
pembrolizumab infusion. Also monitor Blood Pressure, Heart Rate, Temperature, Respiratory Rate and Pain Level 30
minutes after end of first pembrolizumab infusion.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 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
pembrolizumab (KEYTRUDA) 200 mg in sodium chloride 0.9 % 50 mL bag
200 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes with 0.2 or 0.22 micron filter. Do not co-administer other drugs through same infusion line.
Hypersensitivity risk. See Emergency Medications. Patient must be monitored for 30 minutes after first dose of
pembrolizumab.
Follow-Up
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Zztestonc,PedsBeiber [2668824]
11/13/2017 10:56:23 AM Page 3 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be
done locally), Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin,
AST, ALT, Alkaline Phosphatase, Lipase, Amylase; LABS (prior to every EVEN cycle only): TSH, Free T4;
CHEMOTHERAPY ROOM APPOINTMENT: pembrolizumab for 60 minutes.
Cycle 2 –  12/4/2017 through 12/24/2017 (21 days), Planned
Day 1, Cycle 2 –  Planned for 12/4/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Head and Neck Squamous Cell Carcinoma (Advanced); THERAPY: pembrolizumab 200 mg IV Day 1; CYCLE
LENGTH: 21 days; COURSE: until disease progression or maximum 24 months in patients without 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+21 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+21 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
GLUCOSE
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
BUN
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
CALCIUM
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
ALBUMIN
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
PROTEIN, TOTAL
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
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Zztestonc,PedsBeiber [2668824]
11/13/2017 10:56:23 AM Page 4 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

ALT/SGPT
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
LIPASE
Expected: S+21, Expires: S+365, Routine
AMYLASE
Expected: S+21, Expires: S+365, Routine
Pre-Labs (delete all that do not apply)
TSH
Expected: S+21 Approximate, Expires: S+365, Routine
Baseline and prior to every EVEN Cycle only.
T4, FREE
Expected: S+21 Approximate, Expires: S+365, Routine
Baseline and prior to every EVEN Cycle only.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, ALT, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to 100K/µL
or Creatinine greater than 1.5 X ULN or AST greater than 2.5 X ULN (or greater than 5 X ULN if known liver metastases)
or ALT greater than 2.5 X ULN (or greater than 5 X ULN if known liver metastases) or Total Bilirubin greater than 1.5 X
ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to pembrolizumab can occur. For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications. Patient must be monitored for 30 minutes after first dose of
pembrolizumab.
Monitoring Parameters (1)
Notify MD for Systolic Blood Pressure below 100 mmHg (if below pre-infusion Blood Pressure) or for any symptoms of
hypotension.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor Blood Pressure, Heart Rate, Temperature, Respiratory Rate and Pain Level every 15 minutes during
pembrolizumab infusion. Also monitor Blood Pressure, Heart Rate, Temperature, Respiratory Rate and Pain Level 30
minutes after end of first pembrolizumab infusion.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
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Zztestonc,PedsBeiber [2668824]
11/13/2017 10:56:23 AM Page 5 of 16
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 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
pembrolizumab (KEYTRUDA) 200 mg in sodium chloride 0.9 % 50 mL bag
200 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes with 0.2 or 0.22 micron filter. Do not co-administer other drugs through same infusion line.
Hypersensitivity risk. See Emergency Medications. Patient must be monitored for 30 minutes after first dose of
pembrolizumab.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase,
Lipase, Amylase; LABS (prior to every EVEN cycle only): TSH, Free T4; CHEMOTHERAPY ROOM APPOINTMENT:
pembrolizumab for 60 minutes.
Cycle 3 –  12/25/2017 through 1/14/2018 (21 days), Planned
Day 1, Cycle 3 –  Planned for 12/25/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Head and Neck Squamous Cell Carcinoma (Advanced); THERAPY: pembrolizumab 200 mg IV Day 1; CYCLE
LENGTH: 21 days; COURSE: until disease progression or maximum 24 months in patients without 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
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Zztestonc,PedsBeiber [2668824]
11/13/2017 10:56:23 AM Page 6 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

CBC WITHOUT DIFFERENTIAL
Expected: S+21 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+21 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
GLUCOSE
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
BUN
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
CALCIUM
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
ALBUMIN
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
PROTEIN, TOTAL
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
LIPASE
Expected: S+21, Expires: S+365, Routine
AMYLASE
Expected: S+21, Expires: S+365, Routine
Pre-Labs (delete all that do not apply)
TSH
Expected: S+21 Approximate, Expires: S+365, Routine
Baseline and prior to every EVEN Cycle only.
T4, FREE
Expected: S+21 Approximate, Expires: S+365, Routine
Baseline and prior to every EVEN Cycle only.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, ALT, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to 100K/µL
or Creatinine greater than 1.5 X ULN or AST greater than 2.5 X ULN (or greater than 5 X ULN if known liver metastases)
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Zztestonc,PedsBeiber [2668824]
11/13/2017 10:56:23 AM Page 7 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

or ALT greater than 2.5 X ULN (or greater than 5 X ULN if known liver metastases) or Total Bilirubin greater than 1.5 X
ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to pembrolizumab can occur. For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications. Patient must be monitored for 30 minutes after first dose of
pembrolizumab.
Monitoring Parameters (1)
Notify MD for Systolic Blood Pressure below 100 mmHg (if below pre-infusion Blood Pressure) or for any symptoms of
hypotension.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor Blood Pressure, Heart Rate, Temperature, Respiratory Rate and Pain Level every 15 minutes during
pembrolizumab infusion. Also monitor Blood Pressure, Heart Rate, Temperature, Respiratory Rate and Pain Level 30
minutes after end of first pembrolizumab infusion.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 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
pembrolizumab (KEYTRUDA) 200 mg in sodium chloride 0.9 % 50 mL bag
200 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes with 0.2 or 0.22 micron filter. Do not co-administer other drugs through same infusion line.
Hypersensitivity risk. See Emergency Medications. Patient must be monitored for 30 minutes after first dose of
pembrolizumab.
Follow-Up
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Zztestonc,PedsBeiber [2668824]
11/13/2017 10:56:23 AM Page 8 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be
done locally), Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin,
AST, ALT, Alkaline Phosphatase, Lipase, Amylase; LABS (prior to every EVEN cycle only): TSH, Free T4;
CHEMOTHERAPY ROOM APPOINTMENT: pembrolizumab for 60 minutes.
Cycle 4 –  1/15/2018 through 2/4/2018 (21 days), Planned
Day 1, Cycle 4 –  Planned for 1/15/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Head and Neck Squamous Cell Carcinoma (Advanced); THERAPY: pembrolizumab 200 mg IV Day 1; CYCLE
LENGTH: 21 days; COURSE: until disease progression or maximum 24 months in patients without 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+21 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+21 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
GLUCOSE
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
BUN
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
CALCIUM
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
ALBUMIN
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
PROTEIN, TOTAL
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
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Zztestonc,PedsBeiber [2668824]
11/13/2017 10:56:23 AM Page 9 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

ALT/SGPT
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
LIPASE
Expected: S+21, Expires: S+365, Routine
AMYLASE
Expected: S+21, Expires: S+365, Routine
Pre-Labs (delete all that do not apply)
TSH
Expected: S+21 Approximate, Expires: S+365, Routine
Baseline and prior to every EVEN Cycle only.
T4, FREE
Expected: S+21 Approximate, Expires: S+365, Routine
Baseline and prior to every EVEN Cycle only.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, ALT, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to 100K/µL
or Creatinine greater than 1.5 X ULN or AST greater than 2.5 X ULN (or greater than 5 X ULN if known liver metastases)
or ALT greater than 2.5 X ULN (or greater than 5 X ULN if known liver metastases) or Total Bilirubin greater than 1.5 X
ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to pembrolizumab can occur. For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications. Patient must be monitored for 30 minutes after first dose of
pembrolizumab.
Monitoring Parameters (1)
Notify MD for Systolic Blood Pressure below 100 mmHg (if below pre-infusion Blood Pressure) or for any symptoms of
hypotension.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor Blood Pressure, Heart Rate, Temperature, Respiratory Rate and Pain Level every 15 minutes during
pembrolizumab infusion. Also monitor Blood Pressure, Heart Rate, Temperature, Respiratory Rate and Pain Level 30
minutes after end of first pembrolizumab infusion.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
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Zztestonc,PedsBeiber [2668824]
11/13/2017 10:56:23 AM Page 10 of 16
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 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
pembrolizumab (KEYTRUDA) 200 mg in sodium chloride 0.9 % 50 mL bag
200 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes with 0.2 or 0.22 micron filter. Do not co-administer other drugs through same infusion line.
Hypersensitivity risk. See Emergency Medications. Patient must be monitored for 30 minutes after first dose of
pembrolizumab.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase,
Lipase, Amylase; LABS (prior to every EVEN cycle only): TSH, Free T4; CHEMOTHERAPY ROOM APPOINTMENT:
pembrolizumab for 60 minutes.
Cycle 5 –  2/5/2018 through 2/25/2018 (21 days), Planned
Day 1, Cycle 5 –  Planned for 2/5/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Head and Neck Squamous Cell Carcinoma (Advanced); THERAPY: pembrolizumab 200 mg IV Day 1; CYCLE
LENGTH: 21 days; COURSE: until disease progression or maximum 24 months in patients without 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
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Zztestonc,PedsBeiber [2668824]
11/13/2017 10:56:23 AM Page 11 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

CBC WITHOUT DIFFERENTIAL
Expected: S+21 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+21 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
GLUCOSE
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
BUN
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
CALCIUM
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
ALBUMIN
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
PROTEIN, TOTAL
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
LIPASE
Expected: S+21, Expires: S+365, Routine
AMYLASE
Expected: S+21, Expires: S+365, Routine
Pre-Labs (delete all that do not apply)
TSH
Expected: S+21 Approximate, Expires: S+365, Routine
Baseline and prior to every EVEN Cycle only.
T4, FREE
Expected: S+21 Approximate, Expires: S+365, Routine
Baseline and prior to every EVEN Cycle only.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, ALT, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to 100K/µL
or Creatinine greater than 1.5 X ULN or AST greater than 2.5 X ULN (or greater than 5 X ULN if known liver metastases)
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Zztestonc,PedsBeiber [2668824]
11/13/2017 10:56:23 AM Page 12 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

or ALT greater than 2.5 X ULN (or greater than 5 X ULN if known liver metastases) or Total Bilirubin greater than 1.5 X
ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to pembrolizumab can occur. For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications. Patient must be monitored for 30 minutes after first dose of
pembrolizumab.
Monitoring Parameters (1)
Notify MD for Systolic Blood Pressure below 100 mmHg (if below pre-infusion Blood Pressure) or for any symptoms of
hypotension.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor Blood Pressure, Heart Rate, Temperature, Respiratory Rate and Pain Level every 15 minutes during
pembrolizumab infusion. Also monitor Blood Pressure, Heart Rate, Temperature, Respiratory Rate and Pain Level 30
minutes after end of first pembrolizumab infusion.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 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
pembrolizumab (KEYTRUDA) 200 mg in sodium chloride 0.9 % 50 mL bag
200 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes with 0.2 or 0.22 micron filter. Do not co-administer other drugs through same infusion line.
Hypersensitivity risk. See Emergency Medications. Patient must be monitored for 30 minutes after first dose of
pembrolizumab.
Follow-Up
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Zztestonc,PedsBeiber [2668824]
11/13/2017 10:56:23 AM Page 13 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be
done locally), Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin,
AST, ALT, Alkaline Phosphatase, Lipase, Amylase; LABS (prior to every EVEN cycle only): TSH, Free T4;
CHEMOTHERAPY ROOM APPOINTMENT: pembrolizumab for 60 minutes.
Cycle 6 –  2/26/2018 through 3/18/2018 (21 days), Planned
Day 1, Cycle 6 –  Planned for 2/26/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Head and Neck Squamous Cell Carcinoma (Advanced); THERAPY: pembrolizumab 200 mg IV Day 1; CYCLE
LENGTH: 21 days; COURSE: until disease progression or maximum 24 months in patients without 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+21 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+21 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
GLUCOSE
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
BUN
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
CALCIUM
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
ALBUMIN
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
PROTEIN, TOTAL
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
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Zztestonc,PedsBeiber [2668824]
11/13/2017 10:56:23 AM Page 14 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

ALT/SGPT
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
LIPASE
Expected: S+21, Expires: S+365, Routine
AMYLASE
Expected: S+21, Expires: S+365, Routine
Pre-Labs (delete all that do not apply)
TSH
Expected: S+21 Approximate, Expires: S+365, Routine
Baseline and prior to every EVEN Cycle only.
T4, FREE
Expected: S+21 Approximate, Expires: S+365, Routine
Baseline and prior to every EVEN Cycle only.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, ALT, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to 100K/µL
or Creatinine greater than 1.5 X ULN or AST greater than 2.5 X ULN (or greater than 5 X ULN if known liver metastases)
or ALT greater than 2.5 X ULN (or greater than 5 X ULN if known liver metastases) or Total Bilirubin greater than 1.5 X
ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to pembrolizumab can occur. For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications. Patient must be monitored for 30 minutes after first dose of
pembrolizumab.
Monitoring Parameters (1)
Notify MD for Systolic Blood Pressure below 100 mmHg (if below pre-infusion Blood Pressure) or for any symptoms of
hypotension.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor Blood Pressure, Heart Rate, Temperature, Respiratory Rate and Pain Level every 15 minutes during
pembrolizumab infusion. Also monitor Blood Pressure, Heart Rate, Temperature, Respiratory Rate and Pain Level 30
minutes after end of first pembrolizumab infusion.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
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Zztestonc,PedsBeiber [2668824]
11/13/2017 10:56:23 AM Page 15 of 16
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 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
pembrolizumab (KEYTRUDA) 200 mg in sodium chloride 0.9 % 50 mL bag
200 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes with 0.2 or 0.22 micron filter. Do not co-administer other drugs through same infusion line.
Hypersensitivity risk. See Emergency Medications. Patient must be monitored for 30 minutes after first dose of
pembrolizumab.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase,
Lipase, Amylase; LABS (prior to every EVEN cycle only): TSH, Free T4; CHEMOTHERAPY ROOM APPOINTMENT:
pembrolizumab for 60 minutes.
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Zztestonc,PedsBeiber [2668824]
11/13/2017 10:56:23 AM Page 16 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org