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/clinical/cckm-tools/content/beacon-protocols/lung/name-124397-en.cckm

20180122

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UWHC,UWMF,

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

CSC LUNG Durvalumab(28D:1,15) VER 1-22-18 (HL 6721)

CSC LUNG Durvalumab(28D:1,15) VER 1-22-18 (HL 6721) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Lung


CSC LUNG DURVALUMAB(28D:1,15) VER: 1-22-18 –  Properties
Pre-Cycle –  1/15/2018 through 1/21/2018 (7 days), Planned
Day 1, Pre-Cycle –  Planned for 1/15/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: durvalumab 10 mg/kg IV Day 1 and Day 15; CYCLE
LENGTH: 28 days; COURSE: until disease progression (maximum 12 months).
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S Approximate, Expires: S+397, Routine
GLUCOSE
Expected: S Approximate, Expires: S+397, Routine
BUN
Expected: S Approximate, Expires: S+397, Routine
CREATININE
Expected: S Approximate, Expires: S+397, Routine
CALCIUM
Expected: S Approximate, Expires: S+397, Routine
ALBUMIN
Expected: S Approximate, Expires: S+397, Routine
PROTEIN, TOTAL
Expected: S Approximate, Expires: S+397, Routine
BILIRUBIN, TOTAL
Expected: S Approximate, Expires: S+397, Routine
AST/SGOT
Expected: S Approximate, Expires: S+397, Routine
ALT/SGPT
Expected: S Approximate, Expires: S+397, Routine
ALKALINE PHOSPHATASE
Expected: S Approximate, Expires: S+397, Routine
LIPASE
Expected: S Approximate, Expires: S+365, Routine
AMYLASE
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Zztestonc,Edward E [2435061]
1/22/2018 11:13:26 AM Page 1 of 28
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Expected: S Approximate, Expires: S+365, Routine
TSH
Expected: S Approximate, Expires: S+365, Routine
T4, FREE
Expected: S Approximate, Expires: S+365, Routine
CORTISOL
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, E-Prescribe
Cycle 1 –  1/22/2018 through 2/18/2018 (28 days), Planned
Day 1, Cycle 1 –  Planned for 1/22/2018
Treatment Plan Information
Reference Information (1)
NON-SMALL CELL LUNG CANCER: Antonia SJ, et al. N Engl J Med 2017;377(20):1919-29.
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: durvalumab 10 mg/kg IV Day 1 and Day 15; CYCLE
LENGTH: 28 days; COURSE: until disease progression (maximum 12 months).
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, AST, ALT, Total Bilirubin, Creatinine, Glucose.
Verify Labs (2)
Verify pretreatment labs have been obtained: On ODD cycles only: TSH, Free T4 and Cortisol.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/uL or Platelets less than 100K/uL or
Hemoglobin less than 9 g/dL or AST greater than 2.5 X ULN or ALT greater than 2.5 X ULN or Total Bilirubin greater
than 1.5 X ULN or Creatinine greater than 2 X ULN or Glucose greater than 250 mg/dL.
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
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Zztestonc,Edward E [2435061]
1/22/2018 11:13:26 AM Page 2 of 28
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Treatment Parameters (2)
Hold treatment and notify authorizing prescriber: On ODD cycles only: TSH greater than ULN or Cortisol less than or
equal to 3 ug/dL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to durvalumab 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 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine (PEPCID) 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
CUSTOM chemotherapy bag/inj NF
1 each, Intravenous, ONCE, 1 dose Starting when released
Durvalumab 10 mg/kg IV ONCE in 250 mL Normal Saline Bag (final concentration of the diluted solution should be
between 1 mg/mL and 15 mg/mL).
Administer as IV infusion over 60 minutes through an intravenous line containing a sterile, low-protein binding 0.2 or
0.22 micron in-line filter. Do not shake. Do not co-administer other drugs through same intravenous line.
Hypersensitivity reaction to durvalumumab can occur. For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
LABEL: the total time from vial puncture to the start of the administration should not exceed: 24 hours in a refrigerator
at 2 degrees C to 8 degrees C (36 degrees F to 46 degrees F)
4 hours at room temperature up to 25 degrees C (77 degrees F).
Do not freeze.
Follow-Up
DAY 15 FOLLOW-UP
LABS: CBC, ANC, Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT,
Alkaline Phosphatase, Lipase, Amylase; CHEMOTHERAPY ROOM APPOINTMENT: durvalumab for 90 minutes.
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Zztestonc,Edward E [2435061]
1/22/2018 11:13:26 AM Page 3 of 28
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC, Electrolytes,
Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline
Phosphatase, Lipase, Amylase; LABS (ODD CYCLES ONLY): TSH, Free T4, Cortisol; CHEMOTHERAPY
ROOM APPOINTMENT: durvalumab for 90 minutes.
Day 15, Cycle 1 –  Planned for 2/5/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: durvalumab 10 mg/kg IV Day 1 and Day 15; CYCLE
LENGTH: 28 days; COURSE: until disease progression (maximum 12 months).
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
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Zztestonc,Edward E [2435061]
1/22/2018 11:13:26 AM Page 4 of 28
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

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, AST, ALT, Total Bilirubin, Creatinine, Glucose.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/uL or Platelets less than 100K/uL or
Hemoglobin less than 9 g/dL or AST greater than 2.5 X ULN or ALT greater than 2.5 X ULN or Total Bilirubin greater
than 1.5 X ULN or Creatinine greater than 2 X ULN or Glucose greater than 250 mg/dL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to durvalumab 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 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine (PEPCID) 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
CUSTOM chemotherapy bag/inj NF
1 each, Intravenous, ONCE, 1 dose Starting when released
Durvalumab 10 mg/kg IV ONCE in 250 mL Normal Saline Bag (final concentration of the diluted solution should be
between 1 mg/mL and 15 mg/mL).
Administer as IV infusion over 60 minutes through an intravenous line containing a sterile, low-protein binding 0.2 or
0.22 micron in-line filter. Do not shake. Do not co-administer other drugs through same intravenous line.
Hypersensitivity reaction to durvalumumab can occur. For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
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Zztestonc,Edward E [2435061]
1/22/2018 11:13:26 AM Page 5 of 28
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

LABEL: the total time from vial puncture to the start of the administration should not exceed: 24 hours in a refrigerator
at 2 degrees C to 8 degrees C (36 degrees F to 46 degrees F)
4 hours at room temperature up to 25 degrees C (77 degrees F).
Do not freeze.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 –  2/19/2018 through 3/18/2018 (28 days), Planned
Day 1, Cycle 2 –  Planned for 2/19/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: durvalumab 10 mg/kg IV Day 1 and Day 15; CYCLE
LENGTH: 28 days; COURSE: until disease progression (maximum 12 months).
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+15 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+15 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+15 Approximate, Expires: S+365, Normal, Routine
GLUCOSE
Expected: S+15 Approximate, Expires: S+365, Normal, Routine
BUN
Expected: S+15 Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S+15 Approximate, Expires: S+365, Normal, Routine
CALCIUM
Expected: S+15 Approximate, Expires: S+365, Normal, Routine
ALBUMIN
Expected: S+15 Approximate, Expires: S+365, Normal, Routine
PROTEIN, TOTAL
Expected: S+15 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+15 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+15 Approximate, Expires: S+365, Normal, Routine
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Zztestonc,Edward E [2435061]
1/22/2018 11:13:26 AM Page 6 of 28
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

ALT/SGPT
Expected: S+15 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+15 Approximate, Expires: S+365, Normal, Routine
LIPASE
Expected: S+15 Approximate, Expires: S+365, Routine
AMYLASE
Expected: S+15 Approximate, Expires: S+365, Routine
Pre-Labs (delete all that do not apply)
TSH
Expected: S+15, Expires: S+365, Routine
Prior to ODD cycles only.
T4, FREE
Expected: S+15, Expires: S+365, Routine
Prior to ODD cycles only.
CORTISOL
Expected: S+15 Approximate, Expires: S+365, Routine
Prior to every ODD Cycle only.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, AST, ALT, Total Bilirubin, Creatinine, Glucose.
Verify Labs (2)
Verify pretreatment labs have been obtained: On ODD cycles only: TSH, Free T4 and Cortisol.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/uL or Platelets less than 100K/uL or
Hemoglobin less than 9 g/dL or AST greater than 2.5 X ULN or ALT greater than 2.5 X ULN or Total Bilirubin greater
than 1.5 X ULN or Creatinine greater than 2 X ULN or Glucose greater than 250 mg/dL.
Treatment Parameters (2)
Hold treatment and notify authorizing prescriber: On ODD cycles only: TSH greater than ULN or Cortisol less than or
equal to 3 ug/dL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to durvalumab 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.
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Zztestonc,Edward E [2435061]
1/22/2018 11:13:26 AM Page 7 of 28
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

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 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine (PEPCID) 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
CUSTOM chemotherapy bag/inj NF
1 each, Intravenous, ONCE, 1 dose Starting when released
Durvalumab 10 mg/kg IV ONCE in 250 mL Normal Saline Bag (final concentration of the diluted solution should be
between 1 mg/mL and 15 mg/mL).
Administer as IV infusion over 60 minutes through an intravenous line containing a sterile, low-protein binding 0.2 or
0.22 micron in-line filter. Do not shake. Do not co-administer other drugs through same intravenous line.
Hypersensitivity reaction to durvalumumab can occur. For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
LABEL: the total time from vial puncture to the start of the administration should not exceed: 24 hours in a refrigerator
at 2 degrees C to 8 degrees C (36 degrees F to 46 degrees F)
4 hours at room temperature up to 25 degrees C (77 degrees F).
Do not freeze.
Follow-Up
DAY 15 FOLLOW-UP
LABS: CBC, ANC, Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT,
Alkaline Phosphatase, Lipase, Amylase; CHEMOTHERAPY ROOM APPOINTMENT: durvalumab for 90 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC, Electrolytes, Glucose, BUN,
Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Lipase, Amylase; LABS (ODD
CYCLES ONLY): TSH, Free T4, Cortisol; CHEMOTHERAPY ROOM APPOINTMENT: durvalumab for 90 minutes.
Day 15, Cycle 2 –  Planned for 3/5/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: durvalumab 10 mg/kg IV Day 1 and Day 15; CYCLE
LENGTH: 28 days; COURSE: until disease progression (maximum 12 months).
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,Edward E [2435061]
1/22/2018 11:13:26 AM Page 8 of 28
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@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
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, AST, ALT, Total Bilirubin, Creatinine, Glucose.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/uL or Platelets less than 100K/uL or
Hemoglobin less than 9 g/dL or AST greater than 2.5 X ULN or ALT greater than 2.5 X ULN or Total Bilirubin greater
than 1.5 X ULN or Creatinine greater than 2 X ULN or Glucose greater than 250 mg/dL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to durvalumab 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,Edward E [2435061]
1/22/2018 11:13:26 AM Page 9 of 28
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@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 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine (PEPCID) 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
CUSTOM chemotherapy bag/inj NF
1 each, Intravenous, ONCE, 1 dose Starting when released
Durvalumab 10 mg/kg IV ONCE in 250 mL Normal Saline Bag (final concentration of the diluted solution should be
between 1 mg/mL and 15 mg/mL).
Administer as IV infusion over 60 minutes through an intravenous line containing a sterile, low-protein binding 0.2 or
0.22 micron in-line filter. Do not shake. Do not co-administer other drugs through same intravenous line.
Hypersensitivity reaction to durvalumumab can occur. For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
LABEL: the total time from vial puncture to the start of the administration should not exceed: 24 hours in a refrigerator
at 2 degrees C to 8 degrees C (36 degrees F to 46 degrees F)
4 hours at room temperature up to 25 degrees C (77 degrees F).
Do not freeze.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 –  3/19/2018 through 4/15/2018 (28 days), Planned
Day 1, Cycle 3 –  Planned for 3/19/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: durvalumab 10 mg/kg IV Day 1 and Day 15; CYCLE
LENGTH: 28 days; COURSE: until disease progression (maximum 12 months).
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
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Zztestonc,Edward E [2435061]
1/22/2018 11:13:26 AM Page 10 of 28
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Expected: S+15 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+15 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+15 Approximate, Expires: S+365, Normal, Routine
GLUCOSE
Expected: S+15 Approximate, Expires: S+365, Normal, Routine
BUN
Expected: S+15 Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S+15 Approximate, Expires: S+365, Normal, Routine
CALCIUM
Expected: S+15 Approximate, Expires: S+365, Normal, Routine
ALBUMIN
Expected: S+15 Approximate, Expires: S+365, Normal, Routine
PROTEIN, TOTAL
Expected: S+15 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+15 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+15 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+15 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+15 Approximate, Expires: S+365, Normal, Routine
LIPASE
Expected: S+15 Approximate, Expires: S+365, Routine
AMYLASE
Expected: S+15 Approximate, Expires: S+365, Routine
Pre-Labs (delete all that do not apply)
TSH
Expected: S+15, Expires: S+365, Routine
Prior to ODD cycles only.
T4, FREE
Expected: S+15, Expires: S+365, Routine
Prior to ODD cycles only.
CORTISOL
Expected: S+15 Approximate, Expires: S+365, Routine
Prior to every ODD Cycle only.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, AST, ALT, Total Bilirubin, Creatinine, Glucose.
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Zztestonc,Edward E [2435061]
1/22/2018 11:13:26 AM Page 11 of 28
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Verify Labs (2)
Verify pretreatment labs have been obtained: On ODD cycles only: TSH, Free T4 and Cortisol.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/uL or Platelets less than 100K/uL or
Hemoglobin less than 9 g/dL or AST greater than 2.5 X ULN or ALT greater than 2.5 X ULN or Total Bilirubin greater
than 1.5 X ULN or Creatinine greater than 2 X ULN or Glucose greater than 250 mg/dL.
Treatment Parameters (2)
Hold treatment and notify authorizing prescriber: On ODD cycles only: TSH greater than ULN or Cortisol less than or
equal to 3 ug/dL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to durvalumab 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 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine (PEPCID) 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
CUSTOM chemotherapy bag/inj NF
1 each, Intravenous, ONCE, 1 dose Starting when released
Durvalumab 10 mg/kg IV ONCE in 250 mL Normal Saline Bag (final concentration of the diluted solution should be
between 1 mg/mL and 15 mg/mL).
Administer as IV infusion over 60 minutes through an intravenous line containing a sterile, low-protein binding 0.2 or
0.22 micron in-line filter. Do not shake. Do not co-administer other drugs through same intravenous line.
Hypersensitivity reaction to durvalumumab can occur. For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
LABEL: the total time from vial puncture to the start of the administration should not exceed: 24 hours in a refrigerator
at 2 degrees C to 8 degrees C (36 degrees F to 46 degrees F)
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Zztestonc,Edward E [2435061]
1/22/2018 11:13:26 AM Page 12 of 28
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

4 hours at room temperature up to 25 degrees C (77 degrees F).
Do not freeze.
Follow-Up
DAY 15 FOLLOW-UP
LABS: CBC, ANC, Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT,
Alkaline Phosphatase, Lipase, Amylase; CHEMOTHERAPY ROOM APPOINTMENT: durvalumab for 90 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC, Electrolytes, Glucose, BUN,
Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Lipase, Amylase; LABS (ODD
CYCLES ONLY): TSH, Free T4, Cortisol; CHEMOTHERAPY ROOM APPOINTMENT: durvalumab for 90 minutes.
Day 15, Cycle 3 –  Planned for 4/2/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: durvalumab 10 mg/kg IV Day 1 and Day 15; CYCLE
LENGTH: 28 days; COURSE: until disease progression (maximum 12 months).
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
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Zztestonc,Edward E [2435061]
1/22/2018 11:13:26 AM Page 13 of 28
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, AST, ALT, Total Bilirubin, Creatinine, Glucose.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/uL or Platelets less than 100K/uL or
Hemoglobin less than 9 g/dL or AST greater than 2.5 X ULN or ALT greater than 2.5 X ULN or Total Bilirubin greater
than 1.5 X ULN or Creatinine greater than 2 X ULN or Glucose greater than 250 mg/dL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to durvalumab 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 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine (PEPCID) 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
CUSTOM chemotherapy bag/inj NF
1 each, Intravenous, ONCE, 1 dose Starting when released
Durvalumab 10 mg/kg IV ONCE in 250 mL Normal Saline Bag (final concentration of the diluted solution should be
between 1 mg/mL and 15 mg/mL).
Administer as IV infusion over 60 minutes through an intravenous line containing a sterile, low-protein binding 0.2 or
0.22 micron in-line filter. Do not shake. Do not co-administer other drugs through same intravenous line.
Hypersensitivity reaction to durvalumumab can occur. For first and second dose, patient should be treated in a location
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Zztestonc,Edward E [2435061]
1/22/2018 11:13:26 AM Page 14 of 28
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

to optimize emergency care. See Emergency Medications.
LABEL: the total time from vial puncture to the start of the administration should not exceed: 24 hours in a refrigerator
at 2 degrees C to 8 degrees C (36 degrees F to 46 degrees F)
4 hours at room temperature up to 25 degrees C (77 degrees F).
Do not freeze.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 –  4/16/2018 through 5/13/2018 (28 days), Planned
Day 1, Cycle 4 –  Planned for 4/16/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: durvalumab 10 mg/kg IV Day 1 and Day 15; CYCLE
LENGTH: 28 days; COURSE: until disease progression (maximum 12 months).
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+15 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+15 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+15 Approximate, Expires: S+365, Normal, Routine
GLUCOSE
Expected: S+15 Approximate, Expires: S+365, Normal, Routine
BUN
Expected: S+15 Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S+15 Approximate, Expires: S+365, Normal, Routine
CALCIUM
Expected: S+15 Approximate, Expires: S+365, Normal, Routine
ALBUMIN
Expected: S+15 Approximate, Expires: S+365, Normal, Routine
PROTEIN, TOTAL
Expected: S+15 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+15 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
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Zztestonc,Edward E [2435061]
1/22/2018 11:13:26 AM Page 15 of 28
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Expected: S+15 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+15 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+15 Approximate, Expires: S+365, Normal, Routine
LIPASE
Expected: S+15 Approximate, Expires: S+365, Routine
AMYLASE
Expected: S+15 Approximate, Expires: S+365, Routine
Pre-Labs (delete all that do not apply)
TSH
Expected: S+15, Expires: S+365, Routine
Prior to ODD cycles only.
T4, FREE
Expected: S+15, Expires: S+365, Routine
Prior to ODD cycles only.
CORTISOL
Expected: S+15 Approximate, Expires: S+365, Routine
Prior to every ODD Cycle only.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, AST, ALT, Total Bilirubin, Creatinine, Glucose.
Verify Labs (2)
Verify pretreatment labs have been obtained: On ODD cycles only: TSH, Free T4 and Cortisol.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/uL or Platelets less than 100K/uL or
Hemoglobin less than 9 g/dL or AST greater than 2.5 X ULN or ALT greater than 2.5 X ULN or Total Bilirubin greater
than 1.5 X ULN or Creatinine greater than 2 X ULN or Glucose greater than 250 mg/dL.
Treatment Parameters (2)
Hold treatment and notify authorizing prescriber: On ODD cycles only: TSH greater than ULN or Cortisol less than or
equal to 3 ug/dL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to durvalumab 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,Edward E [2435061]
1/22/2018 11:13:26 AM Page 16 of 28
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@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 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine (PEPCID) 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
CUSTOM chemotherapy bag/inj NF
1 each, Intravenous, ONCE, 1 dose Starting when released
Durvalumab 10 mg/kg IV ONCE in 250 mL Normal Saline Bag (final concentration of the diluted solution should be
between 1 mg/mL and 15 mg/mL).
Administer as IV infusion over 60 minutes through an intravenous line containing a sterile, low-protein binding 0.2 or
0.22 micron in-line filter. Do not shake. Do not co-administer other drugs through same intravenous line.
Hypersensitivity reaction to durvalumumab can occur. For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
LABEL: the total time from vial puncture to the start of the administration should not exceed: 24 hours in a refrigerator
at 2 degrees C to 8 degrees C (36 degrees F to 46 degrees F)
4 hours at room temperature up to 25 degrees C (77 degrees F).
Do not freeze.
Follow-Up
DAY 15 FOLLOW-UP
LABS: CBC, ANC, Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT,
Alkaline Phosphatase, Lipase, Amylase; CHEMOTHERAPY ROOM APPOINTMENT: durvalumab for 90 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC, Electrolytes, Glucose, BUN,
Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Lipase, Amylase; LABS (ODD
CYCLES ONLY): TSH, Free T4, Cortisol; CHEMOTHERAPY ROOM APPOINTMENT: durvalumab for 90 minutes.
Day 15, Cycle 4 –  Planned for 4/30/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: durvalumab 10 mg/kg IV Day 1 and Day 15; CYCLE
LENGTH: 28 days; COURSE: until disease progression (maximum 12 months).
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,Edward E [2435061]
1/22/2018 11:13:26 AM Page 17 of 28
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

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
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, AST, ALT, Total Bilirubin, Creatinine, Glucose.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/uL or Platelets less than 100K/uL or
Hemoglobin less than 9 g/dL or AST greater than 2.5 X ULN or ALT greater than 2.5 X ULN or Total Bilirubin greater
than 1.5 X ULN or Creatinine greater than 2 X ULN or Glucose greater than 250 mg/dL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to durvalumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Patient Instructions(1)
Advise patients to contact provider right away with signs of pneumonitis (new or worse cough, chest pain or shortness
of breath) or colitis (abdominal pain; mucus or blood in stool).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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Zztestonc,Edward E [2435061]
1/22/2018 11:13:26 AM Page 18 of 28
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine (PEPCID) 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
CUSTOM chemotherapy bag/inj NF
1 each, Intravenous, ONCE, 1 dose Starting when released
Durvalumab 10 mg/kg IV ONCE in 250 mL Normal Saline Bag (final concentration of the diluted solution should be
between 1 mg/mL and 15 mg/mL).
Administer as IV infusion over 60 minutes through an intravenous line containing a sterile, low-protein binding 0.2 or
0.22 micron in-line filter. Do not shake. Do not co-administer other drugs through same intravenous line.
Hypersensitivity reaction to durvalumumab can occur. For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
LABEL: the total time from vial puncture to the start of the administration should not exceed: 24 hours in a refrigerator
at 2 degrees C to 8 degrees C (36 degrees F to 46 degrees F)
4 hours at room temperature up to 25 degrees C (77 degrees F).
Do not freeze.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 –  5/14/2018 through 6/10/2018 (28 days), Planned
Day 1, Cycle 5 –  Planned for 5/14/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: durvalumab 10 mg/kg IV Day 1 and Day 15; CYCLE
LENGTH: 28 days; COURSE: until disease progression (maximum 12 months).
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,Edward E [2435061]
1/22/2018 11:13:26 AM Page 19 of 28
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

CBC WITHOUT DIFFERENTIAL
Expected: S+15 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+15 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+15 Approximate, Expires: S+365, Normal, Routine
GLUCOSE
Expected: S+15 Approximate, Expires: S+365, Normal, Routine
BUN
Expected: S+15 Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S+15 Approximate, Expires: S+365, Normal, Routine
CALCIUM
Expected: S+15 Approximate, Expires: S+365, Normal, Routine
ALBUMIN
Expected: S+15 Approximate, Expires: S+365, Normal, Routine
PROTEIN, TOTAL
Expected: S+15 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+15 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+15 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+15 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+15 Approximate, Expires: S+365, Normal, Routine
LIPASE
Expected: S+15 Approximate, Expires: S+365, Routine
AMYLASE
Expected: S+15 Approximate, Expires: S+365, Routine
Pre-Labs (delete all that do not apply)
TSH
Expected: S+15, Expires: S+365, Routine
Prior to ODD cycles only.
T4, FREE
Expected: S+15, Expires: S+365, Routine
Prior to ODD cycles only.
CORTISOL
Expected: S+15 Approximate, Expires: S+365, Routine
Prior to every ODD Cycle only.
Treatment Conditions
Verify Labs
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Zztestonc,Edward E [2435061]
1/22/2018 11:13:26 AM Page 20 of 28
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Verify pretreatment labs have been obtained: CBC, AST, ALT, Total Bilirubin, Creatinine, Glucose.
Verify Labs (2)
Verify pretreatment labs have been obtained: On ODD cycles only: TSH, Free T4 and Cortisol.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/uL or Platelets less than 100K/uL or
Hemoglobin less than 9 g/dL or AST greater than 2.5 X ULN or ALT greater than 2.5 X ULN or Total Bilirubin greater
than 1.5 X ULN or Creatinine greater than 2 X ULN or Glucose greater than 250 mg/dL.
Treatment Parameters (2)
Hold treatment and notify authorizing prescriber: On ODD cycles only: TSH greater than ULN or Cortisol less than or
equal to 3 ug/dL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to durvalumab 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 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine (PEPCID) 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
CUSTOM chemotherapy bag/inj NF
1 each, Intravenous, ONCE, 1 dose Starting when released
Durvalumab 10 mg/kg IV ONCE in 250 mL Normal Saline Bag (final concentration of the diluted solution should be
between 1 mg/mL and 15 mg/mL).
Administer as IV infusion over 60 minutes through an intravenous line containing a sterile, low-protein binding 0.2 or
0.22 micron in-line filter. Do not shake. Do not co-administer other drugs through same intravenous line.
Hypersensitivity reaction to durvalumumab can occur. For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
LABEL: the total time from vial puncture to the start of the administration should not exceed: 24 hours in a refrigerator
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Zztestonc,Edward E [2435061]
1/22/2018 11:13:26 AM Page 21 of 28
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

at 2 degrees C to 8 degrees C (36 degrees F to 46 degrees F)
4 hours at room temperature up to 25 degrees C (77 degrees F).
Do not freeze.
Follow-Up
DAY 15 FOLLOW-UP
LABS: CBC, ANC, Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT,
Alkaline Phosphatase, Lipase, Amylase; CHEMOTHERAPY ROOM APPOINTMENT: durvalumab for 90 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC, Electrolytes, Glucose, BUN,
Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Lipase, Amylase; LABS (ODD
CYCLES ONLY): TSH, Free T4, Cortisol; CHEMOTHERAPY ROOM APPOINTMENT: durvalumab for 90 minutes.
Day 15, Cycle 5 –  Planned for 5/28/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: durvalumab 10 mg/kg IV Day 1 and Day 15; CYCLE
LENGTH: 28 days; COURSE: until disease progression (maximum 12 months).
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,Edward E [2435061]
1/22/2018 11:13:26 AM Page 22 of 28
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@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
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, AST, ALT, Total Bilirubin, Creatinine, Glucose.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/uL or Platelets less than 100K/uL or
Hemoglobin less than 9 g/dL or AST greater than 2.5 X ULN or ALT greater than 2.5 X ULN or Total Bilirubin greater
than 1.5 X ULN or Creatinine greater than 2 X ULN or Glucose greater than 250 mg/dL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to durvalumab 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 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine (PEPCID) 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
CUSTOM chemotherapy bag/inj NF
1 each, Intravenous, ONCE, 1 dose Starting when released
Durvalumab 10 mg/kg IV ONCE in 250 mL Normal Saline Bag (final concentration of the diluted solution should be
between 1 mg/mL and 15 mg/mL).
Administer as IV infusion over 60 minutes through an intravenous line containing a sterile, low-protein binding 0.2 or
0.22 micron in-line filter. Do not shake. Do not co-administer other drugs through same intravenous line.
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Zztestonc,Edward E [2435061]
1/22/2018 11:13:26 AM Page 23 of 28
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Hypersensitivity reaction to durvalumumab can occur. For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
LABEL: the total time from vial puncture to the start of the administration should not exceed: 24 hours in a refrigerator
at 2 degrees C to 8 degrees C (36 degrees F to 46 degrees F)
4 hours at room temperature up to 25 degrees C (77 degrees F).
Do not freeze.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 6 –  6/11/2018 through 7/8/2018 (28 days), Planned
Day 1, Cycle 6 –  Planned for 6/11/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: durvalumab 10 mg/kg IV Day 1 and Day 15; CYCLE
LENGTH: 28 days; COURSE: until disease progression (maximum 12 months).
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+15 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+15 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+15 Approximate, Expires: S+365, Normal, Routine
GLUCOSE
Expected: S+15 Approximate, Expires: S+365, Normal, Routine
BUN
Expected: S+15 Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S+15 Approximate, Expires: S+365, Normal, Routine
CALCIUM
Expected: S+15 Approximate, Expires: S+365, Normal, Routine
ALBUMIN
Expected: S+15 Approximate, Expires: S+365, Normal, Routine
PROTEIN, TOTAL
Expected: S+15 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+15 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
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Zztestonc,Edward E [2435061]
1/22/2018 11:13:26 AM Page 24 of 28
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Expected: S+15 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+15 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+15 Approximate, Expires: S+365, Normal, Routine
LIPASE
Expected: S+15 Approximate, Expires: S+365, Routine
AMYLASE
Expected: S+15 Approximate, Expires: S+365, Routine
Pre-Labs (delete all that do not apply)
TSH
Expected: S+15, Expires: S+365, Routine
Prior to ODD cycles only.
T4, FREE
Expected: S+15, Expires: S+365, Routine
Prior to ODD cycles only.
CORTISOL
Expected: S+15 Approximate, Expires: S+365, Routine
Prior to every ODD Cycle only.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, AST, ALT, Total Bilirubin, Creatinine, Glucose.
Verify Labs (2)
Verify pretreatment labs have been obtained: On ODD cycles only: TSH, Free T4 and Cortisol.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/uL or Platelets less than 100K/uL or
Hemoglobin less than 9 g/dL or AST greater than 2.5 X ULN or ALT greater than 2.5 X ULN or Total Bilirubin greater
than 1.5 X ULN or Creatinine greater than 2 X ULN or Glucose greater than 250 mg/dL.
Treatment Parameters (2)
Hold treatment and notify authorizing prescriber: On ODD cycles only: TSH greater than ULN or Cortisol less than or
equal to 3 ug/dL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to durvalumab 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,Edward E [2435061]
1/22/2018 11:13:26 AM Page 25 of 28
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@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 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine (PEPCID) 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
CUSTOM chemotherapy bag/inj NF
1 each, Intravenous, ONCE, 1 dose Starting when released
Durvalumab 10 mg/kg IV ONCE in 250 mL Normal Saline Bag (final concentration of the diluted solution should be
between 1 mg/mL and 15 mg/mL).
Administer as IV infusion over 60 minutes through an intravenous line containing a sterile, low-protein binding 0.2 or
0.22 micron in-line filter. Do not shake. Do not co-administer other drugs through same intravenous line.
Hypersensitivity reaction to durvalumumab can occur. For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
LABEL: the total time from vial puncture to the start of the administration should not exceed: 24 hours in a refrigerator
at 2 degrees C to 8 degrees C (36 degrees F to 46 degrees F)
4 hours at room temperature up to 25 degrees C (77 degrees F).
Do not freeze.
Follow-Up
DAY 15 FOLLOW-UP
LABS: CBC, ANC, Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT,
Alkaline Phosphatase, Lipase, Amylase; CHEMOTHERAPY ROOM APPOINTMENT: durvalumab for 90 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC, Electrolytes, Glucose, BUN,
Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Lipase, Amylase; LABS (ODD
CYCLES ONLY): TSH, Free T4, Cortisol; CHEMOTHERAPY ROOM APPOINTMENT: durvalumab for 90 minutes.
Day 15, Cycle 6 –  Planned for 6/25/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: durvalumab 10 mg/kg IV Day 1 and Day 15; CYCLE
LENGTH: 28 days; COURSE: until disease progression (maximum 12 months).
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,Edward E [2435061]
1/22/2018 11:13:26 AM Page 26 of 28
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

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
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, AST, ALT, Total Bilirubin, Creatinine, Glucose.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/uL or Platelets less than 100K/uL or
Hemoglobin less than 9 g/dL or AST greater than 2.5 X ULN or ALT greater than 2.5 X ULN or Total Bilirubin greater
than 1.5 X ULN or Creatinine greater than 2 X ULN or Glucose greater than 250 mg/dL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to durvalumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Patient Instructions(1)
Advise patients to contact provider right away with signs of pneumonitis (new or worse cough, chest pain or shortness
of breath) or colitis (abdominal pain; mucus or blood in stool).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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Zztestonc,Edward E [2435061]
1/22/2018 11:13:26 AM Page 27 of 28
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine (PEPCID) 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
CUSTOM chemotherapy bag/inj NF
1 each, Intravenous, ONCE, 1 dose Starting when released
Durvalumab 10 mg/kg IV ONCE in 250 mL Normal Saline Bag (final concentration of the diluted solution should be
between 1 mg/mL and 15 mg/mL).
Administer as IV infusion over 60 minutes through an intravenous line containing a sterile, low-protein binding 0.2 or
0.22 micron in-line filter. Do not shake. Do not co-administer other drugs through same intravenous line.
Hypersensitivity reaction to durvalumumab can occur. For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
LABEL: the total time from vial puncture to the start of the administration should not exceed: 24 hours in a refrigerator
at 2 degrees C to 8 degrees C (36 degrees F to 46 degrees F)
4 hours at room temperature up to 25 degrees C (77 degrees F).
Do not freeze.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,Edward E [2435061]
1/22/2018 11:13:26 AM Page 28 of 28
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org