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UWHC,UWMF,

Tools,

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

CSC Lung Nivolumab(28D:1,15) VER 10-25-17 (HL 5601)

CSC Lung Nivolumab(28D:1,15) VER 10-25-17 (HL 5601) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Lung


CSC LUNG NIVOLUMAB(28D:1,15) VER: 10-25-17 (HL 5601) –  Properties
Pre-Cycle –  10/25/2017 through 10/31/2017 (7 days), Planned
Day 1, Pre-Cycle –  Planned for 10/25/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: nivolumab 3 mg/kg IV Day 1 and 15 (maximum dose =
240 mg); CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note: A baseline chest X-ray is recommended prior to initiation of this agent due to the risk of developing pneumonitis.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S Approximate, Expires: S+397, Routine
GLUCOSE
Expected: S Approximate, Expires: S+397, Routine
BUN
Expected: S Approximate, Expires: S+397, Routine
CREATININE
Expected: S Approximate, Expires: S+397, Routine
CALCIUM
Expected: S Approximate, Expires: S+397, Routine
ALBUMIN
Expected: S Approximate, Expires: S+397, Routine
PROTEIN, TOTAL
Expected: S Approximate, Expires: S+397, Routine
BILIRUBIN, TOTAL
Expected: S Approximate, Expires: S+397, Routine
AST/SGOT
Expected: S Approximate, Expires: S+397, Routine
ALT/SGPT
Expected: S Approximate, Expires: S+397, Routine
ALKALINE PHOSPHATASE
Expected: S Approximate, Expires: S+397, Routine
TSH
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Zztestonc,Jeff J [2507481]
11/1/2017 10:26:33 AM Page 1 of 10
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
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.
LIPASE
Expected: S Approximate, Expires: S+365, Routine
AMYLASE
Expected: S Approximate, Expires: S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected: S Approximate, Expires: S+122, Routine
Take Home Medications
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed for nausea/vomiting., 8 mg, Disp-30 tab, R-5, EVERY 8 HOURS PRN
starting S, Local Printer
prochlorperazine (COMPAZINE) 10 MG tab
Take 1 tab by mouth every 6 hours as needed for nausea/vomiting., 10 mg, Disp-30 tab, R-5, EVERY 6 HOURS PRN
starting S, Local Printer
Cycle 1 –  11/1/2017 through 11/28/2017 (28 days), Planned
Day 1, Cycle 1 –  Planned for 11/1/2017
Treatment Plan Information
Reference Information (1)
NON-SMALL CELL LUNG CANCER (ADVANCED): Rizvi NA, et al. Lancet Oncol 2015;16:257-65.
Reference Information (2)
NON-SMALL CELL LUNG CANCER: http://www.fda.gov/Drugs/InformationOnDrugs/ApprovedDrugs/ucm520871.htm.
Accessed December 19, 2016.
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: nivolumab 3 mg/kg IV Day 1 and 15 (maximum dose =
240 mg); CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note: A baseline chest X-ray is recommended prior to initiation of this agent due to the risk of developing pneumonitis.
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, Amylase, Lipase.
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Zztestonc,Jeff J [2507481]
11/1/2017 10:26:33 AM Page 2 of 10
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to
100K/µL or Creatinine greater than 1.5 X ULN or AST greater than 2.5 X ULN (greater than 5 X ULN if known liver
metastasis) or ALT greater than 2.5 X ULN (greater than 5 X ULN if known liver metastasis) or Total Bilirubin greater than
1.5 X ULN or Amylase greater than or equal to 1.6 X ULN or Lipase greater than or equal to 1.6 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to nivolumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Patient Instructions(1)
Advise patients to contact provider right away with signs of pneumonitis (new or worse cough, chest pain or shortness
of breath) or colitis (abdominal pain; mucus or blood in stool).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
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 in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
nivolumab (OPDIVO) 220 mg in sodium chloride 0.9 % 100 mL bag
220 mg (rounded from 240 mg = 3 mg/kg × 80 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 30 Minutes
Maximum dose = 240 mg. Administer with low protein binding in line 0.2 or 0.22 micron filter over 30 minutes. Do not
shake. Do not co-administer other drugs through same infusion line. Hypersensitivity reaction to nivolumab can occur.
For first and second dose, patient should be treated in a location to optimize emergency care. See Emergency
Medications.
Follow-Up
DAY 15 FOLLOW-UP
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Zztestonc,Jeff J [2507481]
11/1/2017 10:26:33 AM Page 3 of 10
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

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;
CHEMOTHERAPY ROOM APPOINTMENT: nivolumab for 60 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase,
Lipase, Amylase; LABS (prior to every EVEN Cycle only): TSH and Free T4; CHEMOTHERAPY ROOM APPOINTMENT:
nivolumab for 60 minutes.
Day 15, Cycle 1 –  Planned for 11/15/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: nivolumab 3 mg/kg IV Day 1 and 15; CYCLE LENGTH: 28
days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
GLUCOSE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
BUN
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
CALCIUM
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALBUMIN
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
PROTEIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
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Zztestonc,Jeff J [2507481]
11/1/2017 10:26:33 AM Page 4 of 10
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
LIPASE
Expected: S+14 Approximate, Expires: S+365, Routine
AMYLASE
Expected: S+14 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, ALT, Total Bilirubin, Amylase, Lipase.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to
100K/µL or Creatinine greater than 1.5 X ULN or AST greater than 2.5 X ULN (greater than 5 X ULN if known liver
metastasis) or ALT greater than 2.5 X ULN (greater than 5 X ULN if known liver metastasis) or Total Bilirubin greater than
1.5 X ULN or Amylase greater than or equal to 1.6 X ULN or Lipase greater than or equal to 1.6 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to nivolumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Patient Instructions(1)
Advise patients to contact provider right away with signs of pneumonitis (new or worse cough, chest pain or shortness
of breath) or colitis (abdominal pain; mucus or blood in stool).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
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 in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
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Zztestonc,Jeff J [2507481]
11/1/2017 10:26:33 AM Page 5 of 10
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Treatment Medications
nivolumab (OPDIVO) 220 mg in sodium chloride 0.9 % 100 mL bag
220 mg (rounded from 240 mg = 3 mg/kg × 80 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 30 Minutes
Maximum dose = 240 mg. Administer with low protein binding in line 0.2 or 0.22 micron filter over 30 minutes. Do not
shake. Do not co-administer other drugs through same infusion line. Hypersensitivity reaction to nivolumab can occur.
For first and second dose, patient should be treated in a location to optimize emergency care. See Emergency
Medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 –  11/29/2017 through 12/26/2017 (28 days), Planned
Day 1, Cycle 2 –  Planned for 11/29/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: nivolumab 3 mg/kg IV Day 1 and 15; CYCLE LENGTH: 28
days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
GLUCOSE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
BUN
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
CALCIUM
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALBUMIN
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
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Zztestonc,Jeff J [2507481]
11/1/2017 10:26:33 AM Page 6 of 10
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

PROTEIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
LIPASE
Expected: S+14 Approximate, Expires: S+365, Routine
AMYLASE
Expected: S+14 Approximate, Expires: S+365, Routine
Pre-Labs (delete all that do not apply)
TSH
Expected: S+14 Approximate, Expires: S+365, Routine
Baseline and prior to every EVEN Cycle only.
T4, FREE
Expected: S+14 Approximate, Expires: S+365, Routine
Baseline and prior to every EVEN Cycle only.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, ALT, Total Bilirubin, Amylase, Lipase.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to
100K/µL or Creatinine greater than 1.5 X ULN or AST greater than 2.5 X ULN (greater than 5 X ULN if known liver
metastasis) or ALT greater than 2.5 X ULN (greater than 5 X ULN if known liver metastasis) or Total Bilirubin greater than
1.5 X ULN or Amylase greater than or equal to 1.6 X ULN or Lipase greater than or equal to 1.6 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to nivolumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Patient Instructions(1)
Advise patients to contact provider right away with signs of pneumonitis (new or worse cough, chest pain or shortness
of breath) or colitis (abdominal pain; mucus or blood in stool).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
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Zztestonc,Jeff J [2507481]
11/1/2017 10:26:33 AM Page 7 of 10
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
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 in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
nivolumab (OPDIVO) 220 mg in sodium chloride 0.9 % 100 mL bag
220 mg (rounded from 240 mg = 3 mg/kg × 80 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 30 Minutes
Maximum dose = 240 mg. Administer with low protein binding in line 0.2 or 0.22 micron filter over 30 minutes. Do not
shake. Do not co-administer other drugs through same infusion line. Hypersensitivity reaction to nivolumab can occur.
For first and second dose, patient should be treated in a location to optimize emergency care. See Emergency
Medications.
Follow-Up
DAY 15 FOLLOW-UP
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;
CHEMOTHERAPY ROOM APPOINTMENT: nivolumab for 60 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase,
Lipase, Amylase; LABS (prior to every EVEN Cycle only): TSH and Free T4; CHEMOTHERAPY ROOM APPOINTMENT:
nivolumab for 60 minutes.
Day 15, Cycle 2 –  Planned for 12/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: nivolumab 3 mg/kg IV Day 1 and 15; CYCLE LENGTH: 28
days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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Zztestonc,Jeff J [2507481]
11/1/2017 10:26:33 AM Page 8 of 10
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+14 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
GLUCOSE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
BUN
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
CALCIUM
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALBUMIN
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
PROTEIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
LIPASE
Expected: S+14 Approximate, Expires: S+365, Routine
AMYLASE
Expected: S+14 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, ALT, Total Bilirubin, Amylase, Lipase.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to
100K/µL or Creatinine greater than 1.5 X ULN or AST greater than 2.5 X ULN (greater than 5 X ULN if known liver
metastasis) or ALT greater than 2.5 X ULN (greater than 5 X ULN if known liver metastasis) or Total Bilirubin greater than
1.5 X ULN or Amylase greater than or equal to 1.6 X ULN or Lipase greater than or equal to 1.6 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to nivolumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Patient Instructions(1)
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Zztestonc,Jeff J [2507481]
11/1/2017 10:26:33 AM Page 9 of 10
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
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 in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
nivolumab (OPDIVO) 220 mg in sodium chloride 0.9 % 100 mL bag
220 mg (rounded from 240 mg = 3 mg/kg × 80 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 30 Minutes
Maximum dose = 240 mg. Administer with low protein binding in line 0.2 or 0.22 micron filter over 30 minutes. Do not
shake. Do not co-administer other drugs through same infusion line. Hypersensitivity reaction to nivolumab can occur.
For first and second dose, patient should be treated in a location to optimize emergency care. See Emergency
Medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 –  12/27/2017 through 1/23/2018 (28 days), Planned
Cycle 4 –  1/24/2018 through 2/20/2018 (28 days), Planned
Cycle 5 –  2/21/2018 through 3/20/2018 (28 days), Planned
Cycle 6 –  3/21/2018 through 4/17/2018 (28 days), Planned
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
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Actions
Zztestonc,Jeff J [2507481]
11/1/2017 10:26:33 AM Page 10 of 10
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org