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201611333

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

CSC Melanoma Interferon Alpha 2-B (Induction) VER 10-3-16 (HL 950)

CSC Melanoma Interferon Alpha 2-B (Induction) VER 10-3-16 (HL 950) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Melanoma


CSC MELANOMA INTERFERON ALPHA 2-B (INDUCTION) VER: 10-3-16 – Properties
Pre-Cycle – 11/28/2016 through 12/4/2016 (7 days), Planned
Day 1, Pre-Cycle – Planned for 11/28/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: INDUCTION: interferon alpha-2B 20 million units/m2 IV Days 1 through 5 weekly for 4
consecutive weeks; CYCLE LENGTH: 7 days; COURSE: 4 cycles.
MAINTENANCE: Induction therapy to be followed by Maintenance Interferon Alpha-2B. Apply Health Link Protocol #951 if patient
will self-administer treatment at home, or #2650 if therapy will be administered in the clinic; CYCLE LENGTH: 28 days; COURSE: 12
cycles. TOTAL TREATMENT LENGTH: 1 year
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
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
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S Approximate, Expires-S+365, Routine
TSH
Expires-S+365, Routine
TSH at baseline and if clinically indicated. MD to delete when not needed.
Take Home Medications
acetaMINOPHEN (TYLENOL) 325 MG tab
Take 1-2 tabs by mouth every 4 hours as needed for fever or pain., 325-650 mg, Disp-100 tab, R-6, EVERY 4 HOURS PRN
starting S
prochlorperazine (COMPAZINE) 10 MG tab
Take 1 tab by mouth every 6 hours as needed for nausea/vomiting., 10 mg, Disp-30 tab, R-5, EVERY 6 HOURS PRN starting S,
Local Printer
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed for nausea/vomiting., 8 mg, Disp-30 tab, R-5, EVERY 8 HOURS PRN starting S,
Local Printer
Cycle 1 Induction – 12/5/2016 through 12/11/2016 (7 days), Planned
Day 1, Cycle 1 Induction – Planned for 12/5/2016
Treatment Plan Information
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ZZtestonc,Andrew [2428787]
11/28/2016 3:35:40 PM Page 1 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Reference Information (1)
MELANOMA: Kirkwood et al. J Clin Oncol 1996;14(1):7-17.
Reference Information (2)
MELANOMA: Moschos SJ et al. J Clin Oncol 2004(1);22:11-3.
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: INDUCTION: interferon alpha-2B 20 million units/m2 IV Days 1 through 5 weekly for 4
consecutive weeks; CYCLE LENGTH: 7 days; COURSE: 4 cycles.
MAINTENANCE: Induction therapy to be followed by Maintenance Interferon Alpha-2B. Apply Health Link Protocol #951 if patient
will self-administer treatment at home, or #2650 if therapy will be administered in the clinic; CYCLE LENGTH: 28 days; COURSE: 12
cycles. TOTAL TREATMENT LENGTH: 1 year
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 and resulted: WBC, ANC, Platelets, Creatinine, AST, ALT, Alkaline Phosphatase, Total
Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 50K/µL or Creatinine
greater than or equal to 1.6 mg/dL or AST greater than 3 X ULN or ALT greater than 3 X ULN or Alkaline Phosphatase greater than
3 X ULN or Total Bilirubin greater than 2 X ULN.
Nursing Procedure, Assessment and Monitoring
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Patient to remain in treatment area for monitoring for 60 minutes after completion of Day 1 and Day 2. On Day 1 and 2, vital signs
are every 15 minutes throughout treatment and for one hour after treatment. On Day 3 and greater, vitals signs are every 15 minutes
during treatment only if Day 1 and 2 doses were tolerated.
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.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
Treatment Medications
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ZZtestonc,Andrew [2428787]
11/28/2016 3:35:40 PM Page 2 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

interferon alfa-2B (INTRON A) 35.8 Million Units in sodium chloride 0.9 % 100 mL bag
35.8 Million Units (20 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Patient to remain in treatment area for monitoring for 60 minutes after the completion of Day 1 and Day 2 interferon doses.
Corticosteroids are NOT allowed for routine use.
Round dose to nearest 1 million units.
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 100 minutes.
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 40 minutes.
DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 40 minutes.
DAY 5 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 40 minutes.
DAY 8 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Creatinine,
Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH; CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 40
minutes.
Day 2, Cycle 1 Induction – Planned for 12/6/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: INDUCTION: interferon alpha-2B 20 million units/m2 IV Days 1 through 5 weekly for 4
consecutive weeks; CYCLE LENGTH: 7 days; COURSE: 4 cycles.
MAINTENANCE: Induction therapy to be followed by Maintenance Interferon Alpha-2B. Apply Health Link Protocol #951 if patient
will self-administer treatment at home, or #2650 if therapy will be administered in the clinic; CYCLE LENGTH: 28 days; COURSE: 12
cycles. TOTAL TREATMENT LENGTH: 1 year
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.
Nursing Procedure, Assessment and Monitoring
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Patient to remain in treatment area for monitoring for 60 minutes after completion of Day 1 and Day 2. On Day 1 and 2, vital signs
are every 15 minutes throughout treatment and for one hour after treatment. On Day 3 and greater, vitals signs are every 15 minutes
during treatment only if Day 1 and 2 doses were tolerated.
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,Andrew [2428787]
11/28/2016 3:35:40 PM Page 3 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
Treatment Medications
interferon alfa-2B (INTRON A) 35.8 Million Units in sodium chloride 0.9 % 100 mL bag
35.8 Million Units (20 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Patient to remain in treatment area for monitoring for 60 minutes after the completion of Day 1 and Day 2 interferon doses.
Corticosteroids are NOT allowed for routine use.
Round dose to nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 1 Induction – Planned for 12/7/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: INDUCTION: interferon alpha-2B 20 million units/m2 IV Days 1 through 5 weekly for 4
consecutive weeks; CYCLE LENGTH: 7 days; COURSE: 4 cycles.
MAINTENANCE: Induction therapy to be followed by Maintenance Interferon Alpha-2B. Apply Health Link Protocol #951 if patient
will self-administer treatment at home, or #2650 if therapy will be administered in the clinic; CYCLE LENGTH: 28 days; COURSE: 12
cycles. TOTAL TREATMENT LENGTH: 1 year
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.
Nursing Procedure, Assessment and Monitoring
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
On Cycle 1 Day 3 and greater, vitals signs are every 15 minutes during treatment only if Day 1 and 2 doses were tolerated. If
treatments on Day 1 and 2 were poorly tolerated, vital signs are every 15 minutes throughout treatment and for one hour after
treatment.
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.
Pre-Medications
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ZZtestonc,Andrew [2428787]
11/28/2016 3:35:40 PM Page 4 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or
15mg/kg per dose for peds <40kg.
Treatment Medications
interferon alfa-2B (INTRON A) 35.8 Million Units in sodium chloride 0.9 % 100 mL bag
35.8 Million Units (20 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Corticosteroids are NOT allowed for routine use.
Round dose to nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 4, Cycle 1 Induction – Planned for 12/8/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: INDUCTION: interferon alpha-2B 20 million units/m2 IV Days 1 through 5 weekly for 4
consecutive weeks; CYCLE LENGTH: 7 days; COURSE: 4 cycles.
MAINTENANCE: Induction therapy to be followed by Maintenance Interferon Alpha-2B. Apply Health Link Protocol #951 if patient
will self-administer treatment at home, or #2650 if therapy will be administered in the clinic; CYCLE LENGTH: 28 days; COURSE: 12
cycles. TOTAL TREATMENT LENGTH: 1 year
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.
Nursing Procedure, Assessment and Monitoring
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
On Cycle 1 Day 3 and greater, vitals signs are every 15 minutes during treatment only if Day 1 and 2 doses were tolerated. If
treatments on Day 1 and 2 were poorly tolerated, vital signs are every 15 minutes throughout treatment and for one hour after
treatment.
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.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
Treatment Medications
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ZZtestonc,Andrew [2428787]
11/28/2016 3:35:40 PM Page 5 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

interferon alfa-2B (INTRON A) 35.8 Million Units in sodium chloride 0.9 % 100 mL bag
35.8 Million Units (20 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Corticosteroids are NOT allowed for routine use.
Round dose to nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 1 Induction – Planned for 12/9/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: INDUCTION: interferon alpha-2B 20 million units/m2 IV Days 1 through 5 weekly for 4
consecutive weeks; CYCLE LENGTH: 7 days; COURSE: 4 cycles.
MAINTENANCE: Induction therapy to be followed by Maintenance Interferon Alpha-2B. Apply Health Link Protocol #951 if patient
will self-administer treatment at home, or #2650 if therapy will be administered in the clinic; CYCLE LENGTH: 28 days; COURSE: 12
cycles. TOTAL TREATMENT LENGTH: 1 year
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.
Nursing Procedure, Assessment and Monitoring
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
On Cycle 1 Day 3 and greater, vitals signs are every 15 minutes during treatment only if Day 1 and 2 doses were tolerated. If
treatments on Day 1 and 2 were poorly tolerated, vital signs are every 15 minutes throughout treatment and for one hour after
treatment.
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.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
Treatment Medications
interferon alfa-2B (INTRON A) 35.8 Million Units in sodium chloride 0.9 % 100 mL bag
35.8 Million Units (20 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
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ZZtestonc,Andrew [2428787]
11/28/2016 3:35:40 PM Page 6 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Corticosteroids are NOT allowed for routine use.
Round dose to nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 Induction – 12/12/2016 through 12/18/2016 (7 days), Planned
Day 1, Cycle 2 Induction – Planned for 12/12/2016
Treatment Plan Information
Reference Information (1)
MELANOMA: Kirkwood et al. J Clin Oncol 1996;14(1):7-17.
Reference Information (2)
MELANOMA: Moschos SJ et al. J Clin Oncol 2004(1);22:11-3.
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: INDUCTION: interferon alpha-2B 20 million units/m2 IV Days 1 through 5 weekly for 4
consecutive weeks; CYCLE LENGTH: 7 days; COURSE: 4 cycles.
MAINTENANCE: Induction therapy to be followed by Maintenance Interferon Alpha-2B. Apply Health Link Protocol #951 if patient
will self-administer treatment at home, or #2650 if therapy will be administered in the clinic; CYCLE LENGTH: 28 days; COURSE: 12
cycles. TOTAL TREATMENT LENGTH: 1 year
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+3 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+3 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+3 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+3 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+3 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+3 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+3 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+3 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, AST, ALT, Alkaline Phosphatase, Total
Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 50K/µL or Creatinine
greater than or equal to 1.6 mg/dL or AST greater than 3 X ULN or ALT greater than 3 X ULN or Alkaline Phosphatase greater than
3 X ULN or Total Bilirubin greater than 2 X ULN.
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ZZtestonc,Andrew [2428787]
11/28/2016 3:35:40 PM Page 7 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Nursing Procedure, Assessment and Monitoring
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
On Cycle 1 Day 3 and greater, vitals signs are every 15 minutes during treatment only if Day 1 and 2 doses were tolerated. If
treatments on Day 1 and 2 were poorly tolerated, vital signs are every 15 minutes throughout treatment and for one hour after
treatment.
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.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
Treatment Medications
interferon alfa-2B (INTRON A) 35.8 Million Units in sodium chloride 0.9 % 100 mL bag
35.8 Million Units (20 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Patient to remain in treatment area for monitoring for 60 minutes after the completion of Day 1 and Day 2 interferon doses.
Corticosteroids are NOT allowed for routine use.
Round dose to nearest 1 million units.
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 40 minutes.
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 40 minutes.
DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 40 minutes.
DAY 5 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 40 minutes.
DAY 8 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Creatinine,
Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH; CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 40
minutes.
Day 2, Cycle 2 Induction – Planned for 12/13/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: INDUCTION: interferon alpha-2B 20 million units/m2 IV Days 1 through 5 weekly for 4
consecutive weeks; CYCLE LENGTH: 7 days; COURSE: 4 cycles.
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ZZtestonc,Andrew [2428787]
11/28/2016 3:35:40 PM Page 8 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

MAINTENANCE: Induction therapy to be followed by Maintenance Interferon Alpha-2B. Apply Health Link Protocol #951 if patient
will self-administer treatment at home, or #2650 if therapy will be administered in the clinic; CYCLE LENGTH: 28 days; COURSE: 12
cycles. TOTAL TREATMENT LENGTH: 1 year
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.
Nursing Procedure, Assessment and Monitoring
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
On Cycle 1 Day 3 and greater, vitals signs are every 15 minutes during treatment only if Day 1 and 2 doses were tolerated. If
treatments on Day 1 and 2 were poorly tolerated, vital signs are every 15 minutes throughout treatment and for one hour after
treatment.
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.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
Treatment Medications
interferon alfa-2B (INTRON A) 35.8 Million Units in sodium chloride 0.9 % 100 mL bag
35.8 Million Units (20 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Patient to remain in treatment area for monitoring for 60 minutes after the completion of Day 1 and Day 2 interferon doses.
Corticosteroids are NOT allowed for routine use.
Round dose to nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 2 Induction – Planned for 12/14/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: INDUCTION: interferon alpha-2B 20 million units/m2 IV Days 1 through 5 weekly for 4
consecutive weeks; CYCLE LENGTH: 7 days; COURSE: 4 cycles.
MAINTENANCE: Induction therapy to be followed by Maintenance Interferon Alpha-2B. Apply Health Link Protocol #951 if patient
will self-administer treatment at home, or #2650 if therapy will be administered in the clinic; CYCLE LENGTH: 28 days; COURSE: 12
cycles. TOTAL TREATMENT LENGTH: 1 year
IV Access
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ZZtestonc,Andrew [2428787]
11/28/2016 3:35:40 PM Page 9 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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.
Nursing Procedure, Assessment and Monitoring
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
On Cycle 1 Day 3 and greater, vitals signs are every 15 minutes during treatment only if Day 1 and 2 doses were tolerated. If
treatments on Day 1 and 2 were poorly tolerated, vital signs are every 15 minutes throughout treatment and for one hour after
treatment.
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.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
Treatment Medications
interferon alfa-2B (INTRON A) 35.8 Million Units in sodium chloride 0.9 % 100 mL bag
35.8 Million Units (20 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Corticosteroids are NOT allowed for routine use.
Round dose to nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 4, Cycle 2 Induction – Planned for 12/15/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: INDUCTION: interferon alpha-2B 20 million units/m2 IV Days 1 through 5 weekly for 4
consecutive weeks; CYCLE LENGTH: 7 days; COURSE: 4 cycles.
MAINTENANCE: Induction therapy to be followed by Maintenance Interferon Alpha-2B. Apply Health Link Protocol #951 if patient
will self-administer treatment at home, or #2650 if therapy will be administered in the clinic; CYCLE LENGTH: 28 days; COURSE: 12
cycles. TOTAL TREATMENT LENGTH: 1 year
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.
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ZZtestonc,Andrew [2428787]
11/28/2016 3:35:40 PM Page 10 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Nursing Procedure, Assessment and Monitoring
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
On Cycle 1 Day 3 and greater, vitals signs are every 15 minutes during treatment only if Day 1 and 2 doses were tolerated. If
treatments on Day 1 and 2 were poorly tolerated, vital signs are every 15 minutes throughout treatment and for one hour after
treatment.
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.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
Treatment Medications
interferon alfa-2B (INTRON A) 35.8 Million Units in sodium chloride 0.9 % 100 mL bag
35.8 Million Units (20 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Corticosteroids are NOT allowed for routine use.
Round dose to nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 2 Induction – Planned for 12/16/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: INDUCTION: interferon alpha-2B 20 million units/m2 IV Days 1 through 5 weekly for 4
consecutive weeks; CYCLE LENGTH: 7 days; COURSE: 4 cycles.
MAINTENANCE: Induction therapy to be followed by Maintenance Interferon Alpha-2B. Apply Health Link Protocol #951 if patient
will self-administer treatment at home, or #2650 if therapy will be administered in the clinic; CYCLE LENGTH: 28 days; COURSE: 12
cycles. TOTAL TREATMENT LENGTH: 1 year
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.
Nursing Procedure, Assessment and Monitoring
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
On Cycle 1 Day 3 and greater, vitals signs are every 15 minutes during treatment only if Day 1 and 2 doses were tolerated. If
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ZZtestonc,Andrew [2428787]
11/28/2016 3:35:40 PM Page 11 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

treatments on Day 1 and 2 were poorly tolerated, vital signs are every 15 minutes throughout treatment and for one hour after
treatment.
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.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
Treatment Medications
interferon alfa-2B (INTRON A) 35.8 Million Units in sodium chloride 0.9 % 100 mL bag
35.8 Million Units (20 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Corticosteroids are NOT allowed for routine use.
Round dose to nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 Induction – 12/19/2016 through 12/25/2016 (7 days), Planned
Day 1, Cycle 3 Induction – Planned for 12/19/2016
Treatment Plan Information
Reference Information (1)
MELANOMA: Kirkwood et al. J Clin Oncol 1996;14(1):7-17.
Reference Information (2)
MELANOMA: Moschos SJ et al. J Clin Oncol 2004(1);22:11-3.
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: INDUCTION: interferon alpha-2B 20 million units/m2 IV Days 1 through 5 weekly for 4
consecutive weeks; CYCLE LENGTH: 7 days; COURSE: 4 cycles.
MAINTENANCE: Induction therapy to be followed by Maintenance Interferon Alpha-2B. Apply Health Link Protocol #951 if patient
will self-administer treatment at home, or #2650 if therapy will be administered in the clinic; CYCLE LENGTH: 28 days; COURSE: 12
cycles. TOTAL TREATMENT LENGTH: 1 year
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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ZZtestonc,Andrew [2428787]
11/28/2016 3:35:40 PM Page 12 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

CBC WITHOUT DIFFERENTIAL
Expected-S+3 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+3 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+3 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+3 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+3 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+3 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+3 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+3 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, AST, ALT, Alkaline Phosphatase, Total
Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 50K/µL or Creatinine
greater than or equal to 1.6 mg/dL or AST greater than 3 X ULN or ALT greater than 3 X ULN or Alkaline Phosphatase greater than
3 X ULN or Total Bilirubin greater than 2 X ULN.
Nursing Procedure, Assessment and Monitoring
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
On Cycle 1 Day 3 and greater, vitals signs are every 15 minutes during treatment only if Day 1 and 2 doses were tolerated. If
treatments on Day 1 and 2 were poorly tolerated, vital signs are every 15 minutes throughout treatment and for one hour after
treatment.
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.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
Treatment Medications
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ZZtestonc,Andrew [2428787]
11/28/2016 3:35:40 PM Page 13 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

interferon alfa-2B (INTRON A) 35.8 Million Units in sodium chloride 0.9 % 100 mL bag
35.8 Million Units (20 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
Patient to remain in treatment area for monitoring for 60 minutes after the completion of Day 1 and Day 2 interferon
doses. Corticosteroids are NOT allowed for routine use.
Round dose to nearest 1 million units.
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 40 minutes.
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 40 minutes.
DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 40 minutes.
DAY 5 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 40 minutes.
DAY 8 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Creatinine,
Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH; CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 40
minutes.
Day 2, Cycle 3 Induction – Planned for 12/20/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: INDUCTION: interferon alpha-2B 20 million units/m2 IV Days 1 through 5 weekly for 4
consecutive weeks; CYCLE LENGTH: 7 days; COURSE: 4 cycles.
MAINTENANCE: Induction therapy to be followed by Maintenance Interferon Alpha-2B. Apply Health Link Protocol #951 if patient
will self-administer treatment at home, or #2650 if therapy will be administered in the clinic; CYCLE LENGTH: 28 days; COURSE: 12
cycles. TOTAL TREATMENT LENGTH: 1 year
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.
Nursing Procedure, Assessment and Monitoring
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
On Cycle 1 Day 3 and greater, vitals signs are every 15 minutes during treatment only if Day 1 and 2 doses were tolerated. If
treatments on Day 1 and 2 were poorly tolerated, vital signs are every 15 minutes throughout treatment and for one hour after
treatment.
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.
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ZZtestonc,Andrew [2428787]
11/28/2016 3:35:40 PM Page 14 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
Treatment Medications
interferon alfa-2B (INTRON A) 35.8 Million Units in sodium chloride 0.9 % 100 mL bag
35.8 Million Units (20 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Patient to remain in treatment area for monitoring for 60 minutes after the completion of Day 1 and Day 2 interferon doses.
Corticosteroids are NOT allowed for routine use.
Round dose to nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 3 Induction – Planned for 12/21/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: INDUCTION: interferon alpha-2B 20 million units/m2 IV Days 1 through 5 weekly for 4
consecutive weeks; CYCLE LENGTH: 7 days; COURSE: 4 cycles.
MAINTENANCE: Induction therapy to be followed by Maintenance Interferon Alpha-2B. Apply Health Link Protocol #951 if patient
will self-administer treatment at home, or #2650 if therapy will be administered in the clinic; CYCLE LENGTH: 28 days; COURSE: 12
cycles. TOTAL TREATMENT LENGTH: 1 year
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.
Nursing Procedure, Assessment and Monitoring
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
On Cycle 1 Day 3 and greater, vitals signs are every 15 minutes during treatment only if Day 1 and 2 doses were tolerated. If
treatments on Day 1 and 2 were poorly tolerated, vital signs are every 15 minutes throughout treatment and for one hour after
treatment.
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.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
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ZZtestonc,Andrew [2428787]
11/28/2016 3:35:40 PM Page 15 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
Treatment Medications
interferon alfa-2B (INTRON A) 35.8 Million Units in sodium chloride 0.9 % 100 mL bag
35.8 Million Units (20 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Corticosteroids are NOT allowed for routine use.
Round dose to nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 4, Cycle 3 Induction – Planned for 12/22/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: INDUCTION: interferon alpha-2B 20 million units/m2 IV Days 1 through 5 weekly for 4
consecutive weeks; CYCLE LENGTH: 7 days; COURSE: 4 cycles.
MAINTENANCE: Induction therapy to be followed by Maintenance Interferon Alpha-2B. Apply Health Link Protocol #951 if patient
will self-administer treatment at home, or #2650 if therapy will be administered in the clinic; CYCLE LENGTH: 28 days; COURSE: 12
cycles. TOTAL TREATMENT LENGTH: 1 year
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.
Nursing Procedure, Assessment and Monitoring
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
On Cycle 1 Day 3 and greater, vitals signs are every 15 minutes during treatment only if Day 1 and 2 doses were tolerated. If
treatments on Day 1 and 2 were poorly tolerated, vital signs are every 15 minutes throughout treatment and for one hour after
treatment.
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.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
Treatment Medications
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ZZtestonc,Andrew [2428787]
11/28/2016 3:35:40 PM Page 16 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

interferon alfa-2B (INTRON A) 35.8 Million Units in sodium chloride 0.9 % 100 mL bag
35.8 Million Units (20 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
Corticosteroids are NOT allowed for routine use.
Round dose to nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 3 Induction – Planned for 12/23/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: INDUCTION: interferon alpha-2B 20 million units/m2 IV Days 1 through 5 weekly for 4
consecutive weeks; CYCLE LENGTH: 7 days; COURSE: 4 cycles.
MAINTENANCE: Induction therapy to be followed by Maintenance Interferon Alpha-2B. Apply Health Link Protocol #951 if patient
will self-administer treatment at home, or #2650 if therapy will be administered in the clinic; CYCLE LENGTH: 28 days; COURSE: 12
cycles. TOTAL TREATMENT LENGTH: 1 year
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.
Nursing Procedure, Assessment and Monitoring
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
On Cycle 1 Day 3 and greater, vitals signs are every 15 minutes during treatment only if Day 1 and 2 doses were tolerated. If
treatments on Day 1 and 2 were poorly tolerated, vital signs are every 15 minutes throughout treatment and for one hour after
treatment.
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.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
Treatment Medications
interferon alfa-2B (INTRON A) 35.8 Million Units in sodium chloride 0.9 % 100 mL bag
35.8 Million Units (20 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Corticosteroids are NOT allowed for routine use.
Round dose to nearest 1 million units.
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ZZtestonc,Andrew [2428787]
11/28/2016 3:35:40 PM Page 17 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 Induction – 12/26/2016 through 1/1/2017 (7 days), Planned
Day 1, Cycle 4 Induction – Planned for 12/26/2016
Treatment Plan Information
Reference Information (1)
MELANOMA: Kirkwood et al. J Clin Oncol 1996;14(1):7-17.
Reference Information (2)
MELANOMA: Moschos SJ et al. J Clin Oncol 2004(1);22:11-3.
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: INDUCTION: interferon alpha-2B 20 million units/m2 IV Days 1 through 5 weekly for 4
consecutive weeks; CYCLE LENGTH: 7 days; COURSE: 4 cycles.
MAINTENANCE: Induction therapy to be followed by Maintenance Interferon Alpha-2B. Apply Health Link Protocol #951 if patient
will self-administer treatment at home, or #2650 if therapy will be administered in the clinic; CYCLE LENGTH: 28 days; COURSE: 12
cycles. TOTAL TREATMENT LENGTH: 1 year
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+3 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+3 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+3 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+3 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+3 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+3 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+3 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+3 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, AST, ALT, Alkaline Phosphatase, Total
Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 50K/µL or Creatinine
greater than or equal to 1.6 mg/dL or AST greater than 3 X ULN or ALT greater than 3 X ULN or Alkaline Phosphatase greater than
3 X ULN or Total Bilirubin greater than 2 X ULN.
Nursing Procedure, Assessment and Monitoring
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ZZtestonc,Andrew [2428787]
11/28/2016 3:35:40 PM Page 18 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
On Cycle 1 Day 3 and greater, vitals signs are every 15 minutes during treatment only if Day 1 and 2 doses were
tolerated. If treatments on Day 1 and 2 were poorly tolerated, vital signs are every 15 minutes throughout treatment
and for one hour after treatment.
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.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
Treatment Medications
interferon alfa-2B (INTRON A) 35.8 Million Units in sodium chloride 0.9 % 100 mL bag
35.8 Million Units (20 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Patient to remain in treatment area for monitoring for 60 minutes after the completion of Day 1 and Day 2 interferon doses.
Corticosteroids are NOT allowed for routine use.
Round dose to nearest 1 million units.
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 40 minutes.
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 40 minutes.
DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 40 minutes.
DAY 5 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 40 minutes.
DAY 8 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Creatinine,
Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH; CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 40
minutes.
Day 2, Cycle 4 Induction – Planned for 12/27/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: INDUCTION: interferon alpha-2B 20 million units/m2 IV Days 1 through 5 weekly for 4
consecutive weeks; CYCLE LENGTH: 7 days; COURSE: 4 cycles.
MAINTENANCE: Induction therapy to be followed by Maintenance Interferon Alpha-2B. Apply Health Link Protocol #951 if patient
will self-administer treatment at home, or #2650 if therapy will be administered in the clinic; CYCLE LENGTH: 28 days; COURSE: 12
cycles. TOTAL TREATMENT LENGTH: 1 year
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ZZtestonc,Andrew [2428787]
11/28/2016 3:35:40 PM Page 19 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
On Cycle 1 Day 3 and greater, vitals signs are every 15 minutes during treatment only if Day 1 and 2 doses were tolerated. If
treatments on Day 1 and 2 were poorly tolerated, vital signs are every 15 minutes throughout treatment and for one hour after
treatment.
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.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
Treatment Medications
interferon alfa-2B (INTRON A) 35.8 Million Units in sodium chloride 0.9 % 100 mL bag
35.8 Million Units (20 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Patient to remain in treatment area for monitoring for 60 minutes after the completion of Day 1 and Day 2 interferon doses.
Corticosteroids are NOT allowed for routine use.
Round dose to nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 4 Induction – Planned for 12/28/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: INDUCTION: interferon alpha-2B 20 million units/m2 IV Days 1 through 5 weekly for 4
consecutive weeks; CYCLE LENGTH: 7 days; COURSE: 4 cycles.
MAINTENANCE: Induction therapy to be followed by Maintenance Interferon Alpha-2B. Apply Health Link Protocol #951 if patient
will self-administer treatment at home, or #2650 if therapy will be administered in the clinic; CYCLE LENGTH: 28 days; COURSE: 12
cycles. TOTAL TREATMENT LENGTH: 1 year
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/28/2016 3:35:40 PM Page 20 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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.
Nursing Procedure, Assessment and Monitoring
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
On Cycle 1 Day 3 and greater, vitals signs are every 15 minutes during treatment only if Day 1 and 2 doses were tolerated. If
treatments on Day 1 and 2 were poorly tolerated, vital signs are every 15 minutes throughout treatment and for one hour after
treatment.
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.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
Treatment Medications
interferon alfa-2B (INTRON A) 35.8 Million Units in sodium chloride 0.9 % 100 mL bag
35.8 Million Units (20 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Corticosteroids are NOT allowed for routine use.
Round dose to nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 4, Cycle 4 Induction – Planned for 12/29/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: INDUCTION: interferon alpha-2B 20 million units/m2 IV Days 1 through 5 weekly for 4
consecutive weeks; CYCLE LENGTH: 7 days; COURSE: 4 cycles.
MAINTENANCE: Induction therapy to be followed by Maintenance Interferon Alpha-2B. Apply Health Link Protocol #951 if patient
will self-administer treatment at home, or #2650 if therapy will be administered in the clinic; CYCLE LENGTH: 28 days; COURSE: 12
cycles. TOTAL TREATMENT LENGTH: 1 year
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.
Nursing Procedure, Assessment and Monitoring
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ZZtestonc,Andrew [2428787]
11/28/2016 3:35:40 PM Page 21 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
On Cycle 1 Day 3 and greater, vitals signs are every 15 minutes during treatment only if Day 1 and 2 doses were
tolerated. If treatments on Day 1 and 2 were poorly tolerated, vital signs are every 15 minutes throughout treatment
and for one hour after treatment.
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.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
Treatment Medications
interferon alfa-2B (INTRON A) 35.8 Million Units in sodium chloride 0.9 % 100 mL bag
35.8 Million Units (20 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Corticosteroids are NOT allowed for routine use.
Round dose to nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 4 Induction – Planned for 12/30/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: INDUCTION: interferon alpha-2B 20 million units/m2 IV Days 1 through 5 weekly for 4
consecutive weeks; CYCLE LENGTH: 7 days; COURSE: 4 cycles.
MAINTENANCE: Induction therapy to be followed by Maintenance Interferon Alpha-2B. Apply Health Link Protocol #951 if patient
will self-administer treatment at home, or #2650 if therapy will be administered in the clinic; CYCLE LENGTH: 28 days; COURSE: 12
cycles. TOTAL TREATMENT LENGTH: 1 year
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.
Nursing Procedure, Assessment and Monitoring
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
On Cycle 1 Day 3 and greater, vitals signs are every 15 minutes during treatment only if Day 1 and 2 doses were tolerated. If
treatments on Day 1 and 2 were poorly tolerated, vital signs are every 15 minutes throughout treatment and for one hour after
treatment.
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ZZtestonc,Andrew [2428787]
11/28/2016 3:35:40 PM Page 22 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
Treatment Medications
interferon alfa-2B (INTRON A) 35.8 Million Units in sodium chloride 0.9 % 100 mL bag
35.8 Million Units (20 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Corticosteroids are NOT allowed for routine use.
Round dose to nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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ZZtestonc,Andrew [2428787]
11/28/2016 3:35:40 PM Page 23 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org