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CSC MELANOMA CYCLE 1-4: IPILIMUMAB(21D:1) FOLLOWED BY CYCLE 5-15 IPILIMUMAB(84D:1) VER 4-27-17 (HL 5837)

CSC MELANOMA CYCLE 1-4: IPILIMUMAB(21D:1) FOLLOWED BY CYCLE 5-15 IPILIMUMAB(84D:1) VER 4-27-17 (HL 5837) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Melanoma


CSC MELANOMA CYCLE 1-4: IPILIMUMAB(21D:1) FOLLOWED BY CYCLE 5-15: IPILIMUMAB(84D:1) VER: 4-27-
17 – Properties
Pre-Cycle – 4/20/2017 through 4/26/2017 (7 days), Planned
Day 1, Pre-Cycle – Planned for 4/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: ipilimumab 10 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 4 cycles
followed by 12 weeks off followed by THERAPY: ipilimumab 10 mg/kg IV Day 1; CYCLE LENGTH: 84 days; COURSE: until disease
progression (up to three years therapy total). NOTE: Cycle 4 cycle length equal to 105 days to accommodate 12 week break
between induction and maintenance with maintenance therapy beginning Week 25 of therapy.
Note to All Staff (1)
Due to the possible effect of treatment with ipilimumab on the immunologic response to infectious disease vaccines, patients must
not have had any infectious disease vaccination (e.g., standard influenza, H1N1 influenza, pneumococcal, meningococcal, tetanus
toxoid) within 4 weeks prior to treatment.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S Approximate, Expires-S+365, Routine
BUN
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
CALCIUM
Expected-S Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S Approximate, Expires-S+365, Routine
PROTEIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, DIRECT
Expected-S Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S Approximate, Expires-S+365, Routine
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Zztestonc,Fiona F [2462287]
4/27/2017 7:40:46 AM Page 1 of 37
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

AMYLASE
Expected-S Approximate, Expires-S+365, Routine
LIPASE
Expected-S Approximate, Expires-S+365, Routine
URIC ACID
Expected-S Approximate, Expires-S+365, Routine
TSH
Expected-S Approximate, Expires-S+365, Routine
T4, TOTAL
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
Expected-S Approximate, Expires-S+365, Routine
Cycle 1 – 4/27/2017 through 5/17/2017 (21 days), Planned
Day 1, Cycle 1 – Planned for 4/27/2017
Treatment Plan Information
Reference Information (1)
MELANOMA: Eggermont AMM, et al. N Engl J Med 2016;375:1845-55.
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: ipilimumab 10 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 4 cycles
followed by 12 weeks off followed by THERAPY: ipilimumab 10 mg/kg IV Day 1; CYCLE LENGTH: 84 days; COURSE: until disease
progression (up to three years therapy total). NOTE: Cycle 4 cycle length equal to 105 days to accommodate 12 week break
between induction and maintenance with maintenance therapy beginning Week 25 of therapy.
Note to All Staff (1)
Due to the possible effect of treatment with ipilimumab on the immunologic response to infectious disease vaccines, patients must
not have had any infectious disease vaccination (e.g., standard influenza, H1N1 influenza, pneumococcal, meningococcal, tetanus
toxoid) within 4 weeks prior to treatment.
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: AST, ALT, Total Bilirubin, Cortisol.
Treatment Parameters
Hold treatment and notify authorizing prescriber for 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 Cortisol less than or equal to 3.0 mcg/dL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
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Zztestonc,Fiona F [2462287]
4/27/2017 7:40:46 AM Page 2 of 37
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

Hypersensitivity reaction to ipilimumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Monitoring Parameters (1)
Administering RN verify completion of ipilimumab REMS Nursing Checklist prior to ipilimumab administration.
Patient Instructions(1)
Please provide patient with Ipilimumab Medication Guide each time patient receives ipilimumab. Go to reference links in navigator.
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
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 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 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
ipilimumab (YERVOY) 10 mg/kg in sodium chloride 0.9 % bag
10 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes with low protein binding tubing and 0.2 or 0.22 micron filter. Hypersensitivity to ipilumumab can occur.
For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Medications.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Sodium, Potassium, Chloride,
Carbon Dioxide, BUN, Creatinine, Calcium, Phosphate, Albumin, Total Protein, Total Bilirubin, Direct Bilirubin, AST, ALT, Alkaline
Phosphatase, LDH, Uric Acid, Lipase, Amylase, TSH, Total T4, Free T4, Cortisol; CHEMOTHERAPY ROOM APPOINTMENT:
ipilimumab for 120 minutes.
Cycle 2 – 5/18/2017 through 6/7/2017 (21 days), Planned
Day 1, Cycle 2 – Planned for 5/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: ipilimumab 10 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 4 cycles
followed by 12 weeks off followed by THERAPY: ipilimumab 10 mg/kg IV Day 1; CYCLE LENGTH: 84 days; COURSE: until disease
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Zztestonc,Fiona F [2462287]
4/27/2017 7:40:46 AM Page 3 of 37
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

progression (up to three years therapy total). NOTE: Cycle 4 cycle length equal to 105 days to accommodate 12 week break
between induction and maintenance with maintenance therapy beginning Week 25 of therapy.
Note to All Staff (1)
Due to the possible effect of treatment with ipilimumab on the immunologic response to infectious disease vaccines, patients must
not have had any infectious disease vaccination (e.g., standard influenza, H1N1 influenza, pneumococcal, meningococcal, tetanus
toxoid) within 4 weeks prior to treatment.
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.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+21 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+21 Approximate, Expires-S+365, Routine
BUN
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+21 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+21 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+21 Approximate, Expires-S+365, Routine
PROTEIN, TOTAL
Expected-S+21, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, DIRECT
Expected-S+21, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+21 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+21 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
AMYLASE
Expected-S+21, Expires-S+365, Routine
LIPASE
Expected-S+21, Expires-S+365, Routine
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Zztestonc,Fiona F [2462287]
4/27/2017 7:40:46 AM Page 4 of 37
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

URIC ACID
Expected-S+21, Expires-S+365, Routine
TSH
Expected-S+21 Approximate, Expires-S+365, Routine
T4, TOTAL
Expected-S Approximate, Expires-S+365, Routine
T4, FREE
Expected-S+21 Approximate, Expires-S+365, Routine
CORTISOL
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: AST, ALT, Total Bilirubin, Cortisol.
Treatment Parameters
Hold and notify authorizing provider for Total Bilirubin greater than 1.5 X ULN or AST greater than 2.5 X ULN or ALT greater than 2.5
X ULN or Cortisol less than or equal to 3.0 mcg/dL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to ipilimumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Monitoring Parameters (1)
Administering RN verify completion of ipilimumab REMS Nursing Checklist prior to ipilimumab administration.
Patient Instructions(1)
Please provide patient with Ipilimumab Medication Guide each time patient receives ipilimumab. Go to reference links in navigator.
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
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 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
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Zztestonc,Fiona F [2462287]
4/27/2017 7:40:46 AM Page 5 of 37
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
ipilimumab (YERVOY) 10 mg/kg in sodium chloride 0.9 % bag
10 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes with low protein binding tubing and 0.2 or 0.22 micron filter. Hypersensitivity to ipilumumab can occur.
For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Medications.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Sodium, Potassium, Chloride,
Carbon Dioxide, BUN, Creatinine, Calcium, Phosphate, Albumin, Total Protein, Total Bilirubin, Direct Bilirubin, AST, ALT, Alkaline
Phosphatase, LDH, Uric Acid, Lipase, Amylase, TSH, Total T4, Free T4, Cortisol; CHEMOTHERAPY ROOM APPOINTMENT:
ipilimumab for 120 minutes.
Cycle 3 – 6/8/2017 through 6/28/2017 (21 days), Planned
Day 1, Cycle 3 – Planned for 6/8/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: ipilimumab 10 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 4 cycles
followed by 12 weeks off followed by THERAPY: ipilimumab 10 mg/kg IV Day 1; CYCLE LENGTH: 84 days; COURSE: until disease
progression (up to three years therapy total). NOTE: Cycle 4 cycle length equal to 105 days to accommodate 12 week break
between induction and maintenance with maintenance therapy beginning Week 25 of therapy.
Note to All Staff (1)
Due to the possible effect of treatment with ipilimumab on the immunologic response to infectious disease vaccines, patients must
not have had any infectious disease vaccination (e.g., standard influenza, H1N1 influenza, pneumococcal, meningococcal, tetanus
toxoid) within 4 weeks prior to treatment.
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.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+21 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+21 Approximate, Expires-S+365, Routine
BUN
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+21 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+21 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+21 Approximate, Expires-S+365, Routine
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Zztestonc,Fiona F [2462287]
4/27/2017 7:40:46 AM Page 6 of 37
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

PROTEIN, TOTAL
Expected-S+21, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, DIRECT
Expected-S+21, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+21 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+21 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
AMYLASE
Expected-S+21, Expires-S+365, Routine
LIPASE
Expected-S+21, Expires-S+365, Routine
URIC ACID
Expected-S+21, Expires-S+365, Routine
TSH
Expected-S+21 Approximate, Expires-S+365, Routine
T4, TOTAL
Expected-S Approximate, Expires-S+365, Routine
T4, FREE
Expected-S+21 Approximate, Expires-S+365, Routine
CORTISOL
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: AST, ALT, Total Bilirubin, Cortisol.
Treatment Parameters
Hold and notify authorizing provider for Total Bilirubin greater than 1.5 X ULN or AST greater than 2.5 X ULN or ALT greater than 2.5
X ULN or Cortisol less than or equal to 3.0 mcg/dL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to ipilimumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Monitoring Parameters (1)
Administering RN verify completion of ipilimumab REMS Nursing Checklist prior to ipilimumab administration.
Patient Instructions(1)
Please provide patient with Ipilimumab Medication Guide each time patient receives ipilimumab. Go to reference links in navigator.
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,Fiona F [2462287]
4/27/2017 7:40:46 AM Page 7 of 37
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
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 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 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
ipilimumab (YERVOY) 10 mg/kg in sodium chloride 0.9 % bag
10 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes with low protein binding tubing and 0.2 or 0.22 micron filter. Hypersensitivity to ipilumumab can occur.
For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Medications.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Sodium, Potassium, Chloride,
Carbon Dioxide, BUN, Creatinine, Calcium, Phosphate, Albumin, Total Protein, Total Bilirubin, Direct Bilirubin, AST, ALT, Alkaline
Phosphatase, LDH, Uric Acid, Lipase, Amylase, TSH, Total T4, Free T4, Cortisol; CHEMOTHERAPY ROOM APPOINTMENT:
ipilimumab for 120 minutes.
Cycle 4 – 6/29/2017 through 10/11/2017 (105 days), Planned
Day 1, Cycle 4 – Planned for 6/29/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: ipilimumab 10 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 4 cycles
followed by 12 weeks off followed by THERAPY: ipilimumab 10 mg/kg IV Day 1; CYCLE LENGTH: 84 days; COURSE: until disease
progression (up to three years therapy total). NOTE: Cycle 4 cycle length equal to 105 days to accommodate 12 week break
between induction and maintenance with maintenance therapy beginning Week 25 of therapy.
Note to All Staff (1)
Due to the possible effect of treatment with ipilimumab on the immunologic response to infectious disease vaccines, patients must
not have had any infectious disease vaccination (e.g., standard influenza, H1N1 influenza, pneumococcal, meningococcal, tetanus
toxoid) within 4 weeks prior to treatment.
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.
Consent
Verify Consent
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Zztestonc,Fiona F [2462287]
4/27/2017 7:40:46 AM Page 8 of 37
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+21 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+21 Approximate, Expires-S+365, Routine
BUN
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+21 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+21 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+21 Approximate, Expires-S+365, Routine
PROTEIN, TOTAL
Expected-S+21, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, DIRECT
Expected-S+21, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+21 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+21 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
AMYLASE
Expected-S+21, Expires-S+365, Routine
LIPASE
Expected-S+21, Expires-S+365, Routine
URIC ACID
Expected-S+21, Expires-S+365, Routine
TSH
Expected-S+21 Approximate, Expires-S+365, Routine
T4, TOTAL
Expected-S Approximate, Expires-S+365, Routine
T4, FREE
Expected-S+21 Approximate, Expires-S+365, Routine
CORTISOL
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
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Zztestonc,Fiona F [2462287]
4/27/2017 7:40:46 AM Page 9 of 37
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

Verify Labs
Verify pretreatment labs have been obtained: AST, ALT, Total Bilirubin, Cortisol.
Treatment Parameters
Hold and notify authorizing provider for Total Bilirubin greater than 1.5 X ULN or AST greater than 2.5 X ULN or ALT greater than 2.5
X ULN or Cortisol less than or equal to 3.0 mcg/dL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to ipilimumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Monitoring Parameters (1)
Administering RN verify completion of ipilimumab REMS Nursing Checklist prior to ipilimumab administration.
Patient Instructions(1)
Please provide patient with Ipilimumab Medication Guide each time patient receives ipilimumab. Go to reference links in navigator.
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
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 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 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
ipilimumab (YERVOY) 10 mg/kg in sodium chloride 0.9 % bag
10 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes with low protein binding tubing and 0.2 or 0.22 micron filter. Hypersensitivity to ipilumumab can occur.
For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Medications.
Follow-Up
Day 106 Follow-Up
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Sodium, Chloride, Carbon Dioxide,
BUN, Creatinine, Calcium, Phosphate, Albumin, Total Protein, Total Bilirubin, Direct Bilirubin, AST, ALT, Alkaline Phosphatase, LDH,
Uric Acid, Lipase, Amylase, TSH, Total T4, Free T4, Cortisol; CHEMOTHERAPY ROOM APPOINTMENT: ipilimumab for 120
minutes.
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Zztestonc,Fiona F [2462287]
4/27/2017 7:40:46 AM Page 10 of 37
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

Cycle 5 – 10/12/2017 through 1/3/2018 (84 days), Planned
Day 1, Cycle 5 – Planned for 10/12/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: ipilimumab 10 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 4 cycles
followed by 12 weeks off followed by THERAPY: ipilimumab 10 mg/kg IV Day 1; CYCLE LENGTH: 84 days; COURSE: until disease
progression (up to three years therapy total). NOTE: Cycle 4 cycle length equal to 105 days to accommodate 12 week break
between induction and maintenance with maintenance therapy beginning Week 25 of therapy.
Note to All Staff (1)
Due to the possible effect of treatment with ipilimumab on the immunologic response to infectious disease vaccines, patients must
not have had any infectious disease vaccination (e.g., standard influenza, H1N1 influenza, pneumococcal, meningococcal, tetanus
toxoid) within 4 weeks prior to treatment.
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.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+105 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+105 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+105 Approximate, Expires-S+365, Routine
BUN
Expected-S+105 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+105 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+105 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+105 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+105 Approximate, Expires-S+365, Routine
PROTEIN, TOTAL
Expected-S+105 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+105 Approximate, Expires-S+365, Routine
BILIRUBIN, DIRECT
Expected-S+105 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+105 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+105 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
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Zztestonc,Fiona F [2462287]
4/27/2017 7:40:46 AM Page 11 of 37
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

Expected-S+105 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+105 Approximate, Expires-S+365, Routine
AMYLASE
Expected-S+105 Approximate, Expires-S+365, Routine
LIPASE
Expected-S+105 Approximate, Expires-S+365, Routine
URIC ACID
Expected-S+105 Approximate, Expires-S+365, Routine
TSH
Expected-S+105 Approximate, Expires-S+365, Routine
T4, TOTAL
Expected-S+105 Approximate, Expires-S+365, Routine
T4, FREE
Expected-S+105 Approximate, Expires-S+365, Routine
CORTISOL
Expected-S+105 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: AST, ALT, Total Bilirubin, Cortisol.
Treatment Parameters
Hold and notify authorizing provider for Total Bilirubin greater than 1.5 X ULN or AST greater than 2.5 X ULN or ALT greater than 2.5
X ULN or Cortisol less than or equal to 3.0 mcg/dL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to ipilimumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Monitoring Parameters (1)
Administering RN verify completion of ipilimumab REMS Nursing Checklist prior to ipilimumab administration.
Patient Instructions(1)
Please provide patient with Ipilimumab Medication Guide each time patient receives ipilimumab. Go to reference links in navigator.
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
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Zztestonc,Fiona F [2462287]
4/27/2017 7:40:46 AM Page 12 of 37
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

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 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 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
ipilimumab (YERVOY) 10 mg/kg in sodium chloride 0.9 % bag
10 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes with low protein binding tubing and 0.2 or 0.22 micron filter. Hypersensitivity to ipilumumab can occur.
For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Medications.
Follow-Up
DAY 85 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Sodium, Chloride, Carbon Dioxide,
BUN, Creatinine, Calcium, Phosphate, Albumin, Total Protein, Total Bilirubin, Direct Bilirubin, AST, ALT, Alkaline Phosphatase, LDH,
Uric Acid, Lipase, Amylase, TSH, Total T4, Free T4, Cortisol; CHEMOTHERAPY ROOM APPOINTMENT: ipilimumab for 120
minutes.
Cycle 6 – 1/4/2018 through 3/28/2018 (84 days), Planned
Day 1, Cycle 6 – Planned for 1/4/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: ipilimumab 10 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 4 cycles
followed by 12 weeks off followed by THERAPY: ipilimumab 10 mg/kg IV Day 1; CYCLE LENGTH: 84 days; COURSE: until disease
progression (up to three years therapy total). NOTE: Cycle 4 cycle length equal to 105 days to accommodate 12 week break
between induction and maintenance with maintenance therapy beginning Week 25 of therapy.
Note to All Staff (1)
Due to the possible effect of treatment with ipilimumab on the immunologic response to infectious disease vaccines, patients must
not have had any infectious disease vaccination (e.g., standard influenza, H1N1 influenza, pneumococcal, meningococcal, tetanus
toxoid) within 4 weeks prior to treatment.
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.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+84 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+84 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+84 Approximate, Expires-S+365, Routine
BUN
Expected-S+84 Approximate, Expires-S+365, Routine
CREATININE
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Zztestonc,Fiona F [2462287]
4/27/2017 7:40:46 AM Page 13 of 37
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

Expected-S+84 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+84 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+84 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+84 Approximate, Expires-S+365, Routine
PROTEIN, TOTAL
Expected-S+84 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+84 Approximate, Expires-S+365, Routine
BILIRUBIN, DIRECT
Expected-S+84 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+84 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+84 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+84 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+84 Approximate, Expires-S+365, Routine
AMYLASE
Expected-S+84 Approximate, Expires-S+365, Routine
LIPASE
Expected-S+84 Approximate, Expires-S+365, Routine
URIC ACID
Expected-S+84 Approximate, Expires-S+365, Routine
TSH
Expected-S+84 Approximate, Expires-S+365, Routine
T4, TOTAL
Expected-S+84 Approximate, Expires-S+365, Routine
T4, FREE
Expected-S+84 Approximate, Expires-S+365, Routine
CORTISOL
Expected-S+84 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: AST, ALT, Total Bilirubin, Cortisol.
Treatment Parameters
Hold and notify authorizing provider for Total Bilirubin greater than 1.5 X ULN or AST greater than 2.5 X ULN or ALT greater than 2.5
X ULN or Cortisol less than or equal to 3.0 mcg/dL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to ipilimumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Monitoring Parameters (1)
Administering RN verify completion of ipilimumab REMS Nursing Checklist prior to ipilimumab administration.
Patient Instructions(1)
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Zztestonc,Fiona F [2462287]
4/27/2017 7:40:46 AM Page 14 of 37
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

Please provide patient with Ipilimumab Medication Guide each time patient receives ipilimumab. Go to reference
links in navigator.
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
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 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 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
ipilimumab (YERVOY) 10 mg/kg in sodium chloride 0.9 % bag
10 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes with low protein binding tubing and 0.2 or 0.22 micron filter. Hypersensitivity to ipilumumab can occur.
For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Medications.
Follow-Up
DAY 85 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Sodium, Chloride, Carbon Dioxide,
BUN, Creatinine, Calcium, Phosphate, Albumin, Total Protein, Total Bilirubin, Direct Bilirubin, AST, ALT, Alkaline Phosphatase, LDH,
Uric Acid, Lipase, Amylase, TSH, Total T4, Free T4, Cortisol; CHEMOTHERAPY ROOM APPOINTMENT: ipilimumab for 120
minutes.
Cycle 7 – 3/29/2018 through 6/20/2018 (84 days), Planned
Day 1, Cycle 7 – Planned for 3/29/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: ipilimumab 10 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 4 cycles
followed by 12 weeks off followed by THERAPY: ipilimumab 10 mg/kg IV Day 1; CYCLE LENGTH: 84 days; COURSE: until disease
progression (up to three years therapy total). NOTE: Cycle 4 cycle length equal to 105 days to accommodate 12 week break
between induction and maintenance with maintenance therapy beginning Week 25 of therapy.
Note to All Staff (1)
Due to the possible effect of treatment with ipilimumab on the immunologic response to infectious disease vaccines, patients must
not have had any infectious disease vaccination (e.g., standard influenza, H1N1 influenza, pneumococcal, meningococcal, tetanus
toxoid) within 4 weeks prior to treatment.
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Zztestonc,Fiona F [2462287]
4/27/2017 7:40:46 AM Page 15 of 37
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

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.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+84 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+84 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+84 Approximate, Expires-S+365, Routine
BUN
Expected-S+84 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+84 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+84 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+84 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+84 Approximate, Expires-S+365, Routine
PROTEIN, TOTAL
Expected-S+84 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+84 Approximate, Expires-S+365, Routine
BILIRUBIN, DIRECT
Expected-S+84 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+84 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+84 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+84 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+84 Approximate, Expires-S+365, Routine
AMYLASE
Expected-S+84 Approximate, Expires-S+365, Routine
LIPASE
Expected-S+84 Approximate, Expires-S+365, Routine
URIC ACID
Expected-S+84 Approximate, Expires-S+365, Routine
TSH
Expected-S+84 Approximate, Expires-S+365, Routine
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Zztestonc,Fiona F [2462287]
4/27/2017 7:40:46 AM Page 16 of 37
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

T4, TOTAL
Expected-S+84 Approximate, Expires-S+365, Routine
T4, FREE
Expected-S+84 Approximate, Expires-S+365, Routine
CORTISOL
Expected-S+84 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: AST, ALT, Total Bilirubin, Cortisol.
Treatment Parameters
Hold and notify authorizing provider for Total Bilirubin greater than 1.5 X ULN or AST greater than 2.5 X ULN or ALT greater than 2.5
X ULN or Cortisol less than or equal to 3.0 mcg/dL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to ipilimumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Monitoring Parameters (1)
Administering RN verify completion of ipilimumab REMS Nursing Checklist prior to ipilimumab administration.
Patient Instructions(1)
Please provide patient with Ipilimumab Medication Guide each time patient receives ipilimumab. Go to reference links in navigator.
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
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 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 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
ipilimumab (YERVOY) 10 mg/kg in sodium chloride 0.9 % bag
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Zztestonc,Fiona F [2462287]
4/27/2017 7:40:46 AM Page 17 of 37
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

10 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes with low protein binding tubing and 0.2 or 0.22 micron filter. Hypersensitivity to ipilumumab can occur.
For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Medications.
Follow-Up
DAY 85 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Sodium, Chloride, Carbon Dioxide,
BUN, Creatinine, Calcium, Phosphate, Albumin, Total Protein, Total Bilirubin, Direct Bilirubin, AST, ALT, Alkaline Phosphatase, LDH,
Uric Acid, Lipase, Amylase, TSH, Total T4, Free T4, Cortisol; CHEMOTHERAPY ROOM APPOINTMENT: ipilimumab for 120
minutes.
Cycle 8 – 6/21/2018 through 9/12/2018 (84 days), Planned
Day 1, Cycle 8 – Planned for 6/21/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: ipilimumab 10 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 4 cycles
followed by 12 weeks off followed by THERAPY: ipilimumab 10 mg/kg IV Day 1; CYCLE LENGTH: 84 days; COURSE: until disease
progression (up to three years therapy total). NOTE: Cycle 4 cycle length equal to 105 days to accommodate 12 week break
between induction and maintenance with maintenance therapy beginning Week 25 of therapy.
Note to All Staff (1)
Due to the possible effect of treatment with ipilimumab on the immunologic response to infectious disease vaccines, patients must
not have had any infectious disease vaccination (e.g., standard influenza, H1N1 influenza, pneumococcal, meningococcal, tetanus
toxoid) within 4 weeks prior to treatment.
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.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+84 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+84 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+84 Approximate, Expires-S+365, Routine
BUN
Expected-S+84 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+84 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+84 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+84 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+84 Approximate, Expires-S+365, Routine
PROTEIN, TOTAL
Expected-S+84 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
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Zztestonc,Fiona F [2462287]
4/27/2017 7:40:46 AM Page 18 of 37
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

Expected-S+84 Approximate, Expires-S+365, Routine
BILIRUBIN, DIRECT
Expected-S+84 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+84 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+84 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+84 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+84 Approximate, Expires-S+365, Routine
AMYLASE
Expected-S+84 Approximate, Expires-S+365, Routine
LIPASE
Expected-S+84 Approximate, Expires-S+365, Routine
URIC ACID
Expected-S+84 Approximate, Expires-S+365, Routine
TSH
Expected-S+84 Approximate, Expires-S+365, Routine
T4, TOTAL
Expected-S+84 Approximate, Expires-S+365, Routine
T4, FREE
Expected-S+84 Approximate, Expires-S+365, Routine
CORTISOL
Expected-S+84 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: AST, ALT, Total Bilirubin, Cortisol.
Treatment Parameters
Hold and notify authorizing provider for Total Bilirubin greater than 1.5 X ULN or AST greater than 2.5 X ULN or ALT greater than 2.5
X ULN or Cortisol less than or equal to 3.0 mcg/dL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to ipilimumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Monitoring Parameters (1)
Administering RN verify completion of ipilimumab REMS Nursing Checklist prior to ipilimumab administration.
Patient Instructions(1)
Please provide patient with Ipilimumab Medication Guide each time patient receives ipilimumab. Go to reference links in navigator.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
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Zztestonc,Fiona F [2462287]
4/27/2017 7:40:46 AM Page 19 of 37
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
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 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 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
ipilimumab (YERVOY) 10 mg/kg in sodium chloride 0.9 % bag
10 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes with low protein binding tubing and 0.2 or 0.22 micron filter. Hypersensitivity to ipilumumab can occur.
For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Medications.
Follow-Up
DAY 85 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Sodium, Chloride, Carbon Dioxide,
BUN, Creatinine, Calcium, Phosphate, Albumin, Total Protein, Total Bilirubin, Direct Bilirubin, AST, ALT, Alkaline Phosphatase, LDH,
Uric Acid, Lipase, Amylase, TSH, Total T4, Free T4, Cortisol; CHEMOTHERAPY ROOM APPOINTMENT: ipilimumab for 120
minutes.
Cycle 9 – 9/13/2018 through 12/5/2018 (84 days), Planned
Day 1, Cycle 9 – Planned for 9/13/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: ipilimumab 10 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 4 cycles
followed by 12 weeks off followed by THERAPY: ipilimumab 10 mg/kg IV Day 1; CYCLE LENGTH: 84 days; COURSE: until disease
progression (up to three years therapy total). NOTE: Cycle 4 cycle length equal to 105 days to accommodate 12 week break
between induction and maintenance with maintenance therapy beginning Week 25 of therapy.
Note to All Staff (1)
Due to the possible effect of treatment with ipilimumab on the immunologic response to infectious disease vaccines, patients must
not have had any infectious disease vaccination (e.g., standard influenza, H1N1 influenza, pneumococcal, meningococcal, tetanus
toxoid) within 4 weeks prior to treatment.
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.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
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Zztestonc,Fiona F [2462287]
4/27/2017 7:40:46 AM Page 20 of 37
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

Expected-S+84 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+84 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+84 Approximate, Expires-S+365, Routine
BUN
Expected-S+84 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+84 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+84 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+84 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+84 Approximate, Expires-S+365, Routine
PROTEIN, TOTAL
Expected-S+84 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+84 Approximate, Expires-S+365, Routine
BILIRUBIN, DIRECT
Expected-S+84 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+84 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+84 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+84 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+84 Approximate, Expires-S+365, Routine
AMYLASE
Expected-S+84 Approximate, Expires-S+365, Routine
LIPASE
Expected-S+84 Approximate, Expires-S+365, Routine
URIC ACID
Expected-S+84 Approximate, Expires-S+365, Routine
TSH
Expected-S+84 Approximate, Expires-S+365, Routine
T4, TOTAL
Expected-S+84 Approximate, Expires-S+365, Routine
T4, FREE
Expected-S+84 Approximate, Expires-S+365, Routine
CORTISOL
Expected-S+84 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: AST, ALT, Total Bilirubin, Cortisol.
Treatment Parameters
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Zztestonc,Fiona F [2462287]
4/27/2017 7:40:46 AM Page 21 of 37
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

Hold and notify authorizing provider for Total Bilirubin greater than 1.5 X ULN or AST greater than 2.5 X ULN or
ALT greater than 2.5 X ULN or Cortisol less than or equal to 3.0 mcg/dL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to ipilimumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Monitoring Parameters (1)
Administering RN verify completion of ipilimumab REMS Nursing Checklist prior to ipilimumab administration.
Patient Instructions(1)
Please provide patient with Ipilimumab Medication Guide each time patient receives ipilimumab. Go to reference links in navigator.
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
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 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 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
ipilimumab (YERVOY) 10 mg/kg in sodium chloride 0.9 % bag
10 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes with low protein binding tubing and 0.2 or 0.22 micron filter. Hypersensitivity to ipilumumab can occur.
For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Medications.
Follow-Up
DAY 85 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Sodium, Chloride, Carbon Dioxide,
BUN, Creatinine, Calcium, Phosphate, Albumin, Total Protein, Total Bilirubin, Direct Bilirubin, AST, ALT, Alkaline Phosphatase, LDH,
Uric Acid, Lipase, Amylase, TSH, Total T4, Free T4, Cortisol; CHEMOTHERAPY ROOM APPOINTMENT: ipilimumab for 120
minutes.
Cycle 10 – 12/6/2018 through 2/27/2019 (84 days), Planned
Day 1, Cycle 10 – Planned for 12/6/2018
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Zztestonc,Fiona F [2462287]
4/27/2017 7:40:46 AM Page 22 of 37
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: ipilimumab 10 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 4 cycles
followed by 12 weeks off followed by THERAPY: ipilimumab 10 mg/kg IV Day 1; CYCLE LENGTH: 84 days; COURSE: until disease
progression (up to three years therapy total). NOTE: Cycle 4 cycle length equal to 105 days to accommodate 12 week break
between induction and maintenance with maintenance therapy beginning Week 25 of therapy.
Note to All Staff (1)
Due to the possible effect of treatment with ipilimumab on the immunologic response to infectious disease vaccines, patients must
not have had any infectious disease vaccination (e.g., standard influenza, H1N1 influenza, pneumococcal, meningococcal, tetanus
toxoid) within 4 weeks prior to treatment.
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.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+84 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+84 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+84 Approximate, Expires-S+365, Routine
BUN
Expected-S+84 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+84 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+84 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+84 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+84 Approximate, Expires-S+365, Routine
PROTEIN, TOTAL
Expected-S+84 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+84 Approximate, Expires-S+365, Routine
BILIRUBIN, DIRECT
Expected-S+84 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+84 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+84 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+84 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+84 Approximate, Expires-S+365, Routine
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Zztestonc,Fiona F [2462287]
4/27/2017 7:40:46 AM Page 23 of 37
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

AMYLASE
Expected-S+84 Approximate, Expires-S+365, Routine
LIPASE
Expected-S+84 Approximate, Expires-S+365, Routine
URIC ACID
Expected-S+84 Approximate, Expires-S+365, Routine
TSH
Expected-S+84 Approximate, Expires-S+365, Routine
T4, TOTAL
Expected-S+84 Approximate, Expires-S+365, Routine
T4, FREE
Expected-S+84 Approximate, Expires-S+365, Routine
CORTISOL
Expected-S+84 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: AST, ALT, Total Bilirubin, Cortisol.
Treatment Parameters
Hold and notify authorizing provider for Total Bilirubin greater than 1.5 X ULN or AST greater than 2.5 X ULN or ALT greater than 2.5
X ULN or Cortisol less than or equal to 3.0 mcg/dL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to ipilimumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Monitoring Parameters (1)
Administering RN verify completion of ipilimumab REMS Nursing Checklist prior to ipilimumab administration.
Patient Instructions(1)
Please provide patient with Ipilimumab Medication Guide each time patient receives ipilimumab. Go to reference links in navigator.
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
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 4 mg
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Zztestonc,Fiona F [2462287]
4/27/2017 7:40:46 AM Page 24 of 37
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 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
ipilimumab (YERVOY) 10 mg/kg in sodium chloride 0.9 % bag
10 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes with low protein binding tubing and 0.2 or 0.22 micron filter. Hypersensitivity to ipilumumab can occur.
For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Medications.
Follow-Up
DAY 85 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Sodium, Chloride, Carbon Dioxide,
BUN, Creatinine, Calcium, Phosphate, Albumin, Total Protein, Total Bilirubin, Direct Bilirubin, AST, ALT, Alkaline Phosphatase, LDH,
Uric Acid, Lipase, Amylase, TSH, Total T4, Free T4, Cortisol; CHEMOTHERAPY ROOM APPOINTMENT: ipilimumab for 120
minutes.
Cycle 11 – 2/28/2019 through 5/22/2019 (84 days), Planned
Day 1, Cycle 11 – Planned for 2/28/2019
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: ipilimumab 10 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 4 cycles
followed by 12 weeks off followed by THERAPY: ipilimumab 10 mg/kg IV Day 1; CYCLE LENGTH: 84 days; COURSE: until disease
progression (up to three years therapy total). NOTE: Cycle 4 cycle length equal to 105 days to accommodate 12 week break
between induction and maintenance with maintenance therapy beginning Week 25 of therapy.
Note to All Staff (1)
Due to the possible effect of treatment with ipilimumab on the immunologic response to infectious disease vaccines, patients must
not have had any infectious disease vaccination (e.g., standard influenza, H1N1 influenza, pneumococcal, meningococcal, tetanus
toxoid) within 4 weeks prior to treatment.
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.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+84 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+84 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+84 Approximate, Expires-S+365, Routine
BUN
Expected-S+84 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+84 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+84 Approximate, Expires-S+365, Routine
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Zztestonc,Fiona F [2462287]
4/27/2017 7:40:46 AM Page 25 of 37
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

PHOSPHATE
Expected-S+84 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+84 Approximate, Expires-S+365, Routine
PROTEIN, TOTAL
Expected-S+84 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+84 Approximate, Expires-S+365, Routine
BILIRUBIN, DIRECT
Expected-S+84 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+84 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+84 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+84 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+84 Approximate, Expires-S+365, Routine
AMYLASE
Expected-S+84 Approximate, Expires-S+365, Routine
LIPASE
Expected-S+84 Approximate, Expires-S+365, Routine
URIC ACID
Expected-S+84 Approximate, Expires-S+365, Routine
TSH
Expected-S+84 Approximate, Expires-S+365, Routine
T4, TOTAL
Expected-S+84 Approximate, Expires-S+365, Routine
T4, FREE
Expected-S+84 Approximate, Expires-S+365, Routine
CORTISOL
Expected-S+84 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: AST, ALT, Total Bilirubin, Cortisol.
Treatment Parameters
Hold and notify authorizing provider for Total Bilirubin greater than 1.5 X ULN or AST greater than 2.5 X ULN or ALT greater than 2.5
X ULN or Cortisol less than or equal to 3.0 mcg/dL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to ipilimumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Monitoring Parameters (1)
Administering RN verify completion of ipilimumab REMS Nursing Checklist prior to ipilimumab administration.
Patient Instructions(1)
Please provide patient with Ipilimumab Medication Guide each time patient receives ipilimumab. Go to reference links in navigator.
Flush Venous Access Device per Guidelines
Order details
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Zztestonc,Fiona F [2462287]
4/27/2017 7:40:46 AM Page 26 of 37
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
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 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 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
ipilimumab (YERVOY) 10 mg/kg in sodium chloride 0.9 % bag
10 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes with low protein binding tubing and 0.2 or 0.22 micron filter. Hypersensitivity to ipilumumab can occur.
For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Medications.
Follow-Up
DAY 85 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Sodium, Chloride, Carbon Dioxide,
BUN, Creatinine, Calcium, Phosphate, Albumin, Total Protein, Total Bilirubin, Direct Bilirubin, AST, ALT, Alkaline Phosphatase, LDH,
Uric Acid, Lipase, Amylase, TSH, Total T4, Free T4, Cortisol; CHEMOTHERAPY ROOM APPOINTMENT: ipilimumab for 120
minutes.
Cycle 12 – 5/23/2019 through 8/14/2019 (84 days), Planned
Day 1, Cycle 12 – Planned for 5/23/2019
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: ipilimumab 10 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 4 cycles
followed by 12 weeks off followed by THERAPY: ipilimumab 10 mg/kg IV Day 1; CYCLE LENGTH: 84 days; COURSE: until disease
progression (up to three years therapy total). NOTE: Cycle 4 cycle length equal to 105 days to accommodate 12 week break
between induction and maintenance with maintenance therapy beginning Week 25 of therapy.
Note to All Staff (1)
Due to the possible effect of treatment with ipilimumab on the immunologic response to infectious disease vaccines, patients must
not have had any infectious disease vaccination (e.g., standard influenza, H1N1 influenza, pneumococcal, meningococcal, tetanus
toxoid) within 4 weeks prior to treatment.
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Fiona F [2462287]
4/27/2017 7:40:46 AM Page 27 of 37
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

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.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+84 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+84 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+84 Approximate, Expires-S+365, Routine
BUN
Expected-S+84 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+84 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+84 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+84 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+84 Approximate, Expires-S+365, Routine
PROTEIN, TOTAL
Expected-S+84 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+84 Approximate, Expires-S+365, Routine
BILIRUBIN, DIRECT
Expected-S+84 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+84 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+84 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+84 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+84 Approximate, Expires-S+365, Routine
AMYLASE
Expected-S+84 Approximate, Expires-S+365, Routine
LIPASE
Expected-S+84 Approximate, Expires-S+365, Routine
URIC ACID
Expected-S+84 Approximate, Expires-S+365, Routine
TSH
Expected-S+84 Approximate, Expires-S+365, Routine
T4, TOTAL
Expected-S+84 Approximate, Expires-S+365, Routine
T4, FREE
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Zztestonc,Fiona F [2462287]
4/27/2017 7:40:46 AM Page 28 of 37
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

Expected-S+84 Approximate, Expires-S+365, Routine
CORTISOL
Expected-S+84 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: AST, ALT, Total Bilirubin, Cortisol.
Treatment Parameters
Hold and notify authorizing provider for Total Bilirubin greater than 1.5 X ULN or AST greater than 2.5 X ULN or ALT greater than 2.5
X ULN or Cortisol less than or equal to 3.0 mcg/dL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to ipilimumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Monitoring Parameters (1)
Administering RN verify completion of ipilimumab REMS Nursing Checklist prior to ipilimumab administration.
Patient Instructions(1)
Please provide patient with Ipilimumab Medication Guide each time patient receives ipilimumab. Go to reference links in navigator.
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
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 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 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
ipilimumab (YERVOY) 10 mg/kg in sodium chloride 0.9 % bag
10 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes with low protein binding tubing and 0.2 or 0.22 micron filter. Hypersensitivity to ipilumumab can occur.
For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Medications.
Follow-Up
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Zztestonc,Fiona F [2462287]
4/27/2017 7:40:46 AM Page 29 of 37
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

DAY 85 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Sodium, Chloride,
Carbon Dioxide, BUN, Creatinine, Calcium, Phosphate, Albumin, Total Protein, Total Bilirubin, Direct Bilirubin, AST,
ALT, Alkaline Phosphatase, LDH, Uric Acid, Lipase, Amylase, TSH, Total T4, Free T4, Cortisol; CHEMOTHERAPY
ROOM APPOINTMENT: ipilimumab for 120 minutes.
Cycle 13 – 8/15/2019 through 11/6/2019 (84 days), Planned
Day 1, Cycle 13 – Planned for 8/15/2019
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: ipilimumab 10 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 4 cycles
followed by 12 weeks off followed by THERAPY: ipilimumab 10 mg/kg IV Day 1; CYCLE LENGTH: 84 days; COURSE: until disease
progression (up to three years therapy total). NOTE: Cycle 4 cycle length equal to 105 days to accommodate 12 week break
between induction and maintenance with maintenance therapy beginning Week 25 of therapy.
Note to All Staff (1)
Due to the possible effect of treatment with ipilimumab on the immunologic response to infectious disease vaccines, patients must
not have had any infectious disease vaccination (e.g., standard influenza, H1N1 influenza, pneumococcal, meningococcal, tetanus
toxoid) within 4 weeks prior to treatment.
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.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+84 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+84 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+84 Approximate, Expires-S+365, Routine
BUN
Expected-S+84 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+84 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+84 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+84 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+84 Approximate, Expires-S+365, Routine
PROTEIN, TOTAL
Expected-S+84 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+84 Approximate, Expires-S+365, Routine
BILIRUBIN, DIRECT
Expected-S+84 Approximate, Expires-S+365, Routine
AST/SGOT
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Zztestonc,Fiona F [2462287]
4/27/2017 7:40:46 AM Page 30 of 37
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

Expected-S+84 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+84 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+84 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+84 Approximate, Expires-S+365, Routine
AMYLASE
Expected-S+84 Approximate, Expires-S+365, Routine
LIPASE
Expected-S+84 Approximate, Expires-S+365, Routine
URIC ACID
Expected-S+84 Approximate, Expires-S+365, Routine
TSH
Expected-S+84 Approximate, Expires-S+365, Routine
T4, TOTAL
Expected-S+84 Approximate, Expires-S+365, Routine
T4, FREE
Expected-S+84 Approximate, Expires-S+365, Routine
CORTISOL
Expected-S+84 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: AST, ALT, Total Bilirubin, Cortisol.
Treatment Parameters
Hold and notify authorizing provider for Total Bilirubin greater than 1.5 X ULN or AST greater than 2.5 X ULN or ALT greater than 2.5
X ULN or Cortisol less than or equal to 3.0 mcg/dL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to ipilimumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Monitoring Parameters (1)
Administering RN verify completion of ipilimumab REMS Nursing Checklist prior to ipilimumab administration.
Patient Instructions(1)
Please provide patient with Ipilimumab Medication Guide each time patient receives ipilimumab. Go to reference links in navigator.
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.
Hydration
sodium chloride 0.9 % infusion
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Zztestonc,Fiona F [2462287]
4/27/2017 7:40:46 AM Page 31 of 37
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
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 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 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
ipilimumab (YERVOY) 10 mg/kg in sodium chloride 0.9 % bag
10 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes with low protein binding tubing and 0.2 or 0.22 micron filter. Hypersensitivity to ipilumumab can occur.
For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Medications.
Follow-Up
DAY 85 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Sodium, Chloride, Carbon Dioxide,
BUN, Creatinine, Calcium, Phosphate, Albumin, Total Protein, Total Bilirubin, Direct Bilirubin, AST, ALT, Alkaline Phosphatase, LDH,
Uric Acid, Lipase, Amylase, TSH, Total T4, Free T4, Cortisol; CHEMOTHERAPY ROOM APPOINTMENT: ipilimumab for 120
minutes.
Cycle 14 – 11/7/2019 through 1/29/2020 (84 days), Planned
Day 1, Cycle 14 – Planned for 11/7/2019
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: ipilimumab 10 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 4 cycles
followed by 12 weeks off followed by THERAPY: ipilimumab 10 mg/kg IV Day 1; CYCLE LENGTH: 84 days; COURSE: until disease
progression (up to three years therapy total). NOTE: Cycle 4 cycle length equal to 105 days to accommodate 12 week break
between induction and maintenance with maintenance therapy beginning Week 25 of therapy.
Note to All Staff (1)
Due to the possible effect of treatment with ipilimumab on the immunologic response to infectious disease vaccines, patients must
not have had any infectious disease vaccination (e.g., standard influenza, H1N1 influenza, pneumococcal, meningococcal, tetanus
toxoid) within 4 weeks prior to treatment.
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.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+84 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+84 Approximate, Expires-S+365, Routine
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Zztestonc,Fiona F [2462287]
4/27/2017 7:40:46 AM Page 32 of 37
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

GLUCOSE
Expected-S+84 Approximate, Expires-S+365, Routine
BUN
Expected-S+84 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+84 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+84 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+84 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+84 Approximate, Expires-S+365, Routine
PROTEIN, TOTAL
Expected-S+84 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+84 Approximate, Expires-S+365, Routine
BILIRUBIN, DIRECT
Expected-S+84 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+84 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+84 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+84 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+84 Approximate, Expires-S+365, Routine
AMYLASE
Expected-S+84 Approximate, Expires-S+365, Routine
LIPASE
Expected-S+84 Approximate, Expires-S+365, Routine
URIC ACID
Expected-S+84 Approximate, Expires-S+365, Routine
TSH
Expected-S+84 Approximate, Expires-S+365, Routine
T4, TOTAL
Expected-S+84 Approximate, Expires-S+365, Routine
T4, FREE
Expected-S+84 Approximate, Expires-S+365, Routine
CORTISOL
Expected-S+84 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: AST, ALT, Total Bilirubin, Cortisol.
Treatment Parameters
Hold and notify authorizing provider for Total Bilirubin greater than 1.5 X ULN or AST greater than 2.5 X ULN or ALT greater than 2.5
X ULN or Cortisol less than or equal to 3.0 mcg/dL.
Nursing Procedure, Assessment and Monitoring
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Zztestonc,Fiona F [2462287]
4/27/2017 7:40:46 AM Page 33 of 37
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

Hypersensitivity Monitoring (1)
Hypersensitivity reaction to ipilimumab can occur. For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Monitoring Parameters (1)
Administering RN verify completion of ipilimumab REMS Nursing Checklist prior to ipilimumab administration.
Patient Instructions(1)
Please provide patient with Ipilimumab Medication Guide each time patient receives ipilimumab. Go to reference links in navigator.
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
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 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 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
ipilimumab (YERVOY) 10 mg/kg in sodium chloride 0.9 % bag
10 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes with low protein binding tubing and 0.2 or 0.22 micron filter. Hypersensitivity to ipilumumab can occur.
For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Medications.
Follow-Up
DAY 85 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Sodium, Chloride, Carbon Dioxide,
BUN, Creatinine, Calcium, Phosphate, Albumin, Total Protein, Total Bilirubin, Direct Bilirubin, AST, ALT, Alkaline Phosphatase, LDH,
Uric Acid, Lipase, Amylase, TSH, Total T4, Free T4, Cortisol; CHEMOTHERAPY ROOM APPOINTMENT: ipilimumab for 120
minutes.
Cycle 15 – 1/30/2020 through 4/22/2020 (84 days), Planned
Day 1, Cycle 15 – Planned for 1/30/2020
Treatment Plan Information
Treatment Plan Summary
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Zztestonc,Fiona F [2462287]
4/27/2017 7:40:46 AM Page 34 of 37
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

DISEASE: Melanoma (Adjuvant); THERAPY: ipilimumab 10 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE: 4 cycles
followed by 12 weeks off followed by THERAPY: ipilimumab 10 mg/kg IV Day 1; CYCLE LENGTH: 84 days; COURSE: until disease
progression (up to three years therapy total). NOTE: Cycle 4 cycle length equal to 105 days to accommodate 12 week break
between induction and maintenance with maintenance therapy beginning Week 25 of therapy.
Note to All Staff (1)
Due to the possible effect of treatment with ipilimumab on the immunologic response to infectious disease vaccines, patients must
not have had any infectious disease vaccination (e.g., standard influenza, H1N1 influenza, pneumococcal, meningococcal, tetanus
toxoid) within 4 weeks prior to treatment.
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.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+84 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+84 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+84 Approximate, Expires-S+365, Routine
BUN
Expected-S+84 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+84 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+84 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+84 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+84 Approximate, Expires-S+365, Routine
PROTEIN, TOTAL
Expected-S+84 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+84 Approximate, Expires-S+365, Routine
BILIRUBIN, DIRECT
Expected-S+84 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+84 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+84 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+84 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+84 Approximate, Expires-S+365, Routine
AMYLASE
Expected-S+84 Approximate, Expires-S+365, Routine
LIPASE
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Zztestonc,Fiona F [2462287]
4/27/2017 7:40:46 AM Page 35 of 37
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

Expected-S+84 Approximate, Expires-S+365, Routine
URIC ACID
Expected-S+84 Approximate, Expires-S+365, Routine
TSH
Expected-S+84 Approximate, Expires-S+365, Routine
T4, TOTAL
Expected-S+84 Approximate, Expires-S+365, Routine
T4, FREE
Expected-S+84 Approximate, Expires-S+365, Routine
CORTISOL
Expected-S+84 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: AST, ALT, Total Bilirubin, Cortisol.
Treatment Parameters
Hold and notify authorizing provider for Total Bilirubin greater than 1.5 X ULN or AST greater than 2.5 X ULN or ALT greater than 2.5
X ULN or Cortisol less than or equal to 3.0 mcg/dL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to ipilimumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Monitoring Parameters (1)
Administering RN verify completion of ipilimumab REMS Nursing Checklist prior to ipilimumab administration.
Patient Instructions(1)
Please provide patient with Ipilimumab Medication Guide each time patient receives ipilimumab. Go to reference links in navigator.
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
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 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
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Zztestonc,Fiona F [2462287]
4/27/2017 7:40:46 AM Page 36 of 37
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
ipilimumab (YERVOY) 10 mg/kg in sodium chloride 0.9 % bag
10 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Administer over 90 minutes with low protein binding tubing and 0.2 or 0.22 micron filter. Hypersensitivity to ipilumumab can occur.
For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Medications.
Follow-Up
DAY 85 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Sodium, Chloride, Carbon Dioxide,
BUN, Creatinine, Calcium, Phosphate, Albumin, Total Protein, Total Bilirubin, Direct Bilirubin, AST, ALT, Alkaline Phosphatase, LDH,
Uric Acid, Lipase, Amylase, TSH, Total T4, Free T4, Cortisol; CHEMOTHERAPY ROOM APPOINTMENT: ipilimumab for 120
minutes.
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Zztestonc,Fiona F [2462287]
4/27/2017 7:40:46 AM Page 37 of 37
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority