/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/beacon-protocols/,/clinical/cckm-tools/content/beacon-protocols/melanoma/,

/clinical/cckm-tools/content/beacon-protocols/melanoma/name-96981-en.cckm

201611333

page

100

UWHC,UWMF,

Tools,

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

CSC Melanoma Interferon Alpha 2-B (Maintenance) Clinic Administered VER 10-3-16 (HL 2650)

CSC Melanoma Interferon Alpha 2-B (Maintenance) Clinic Administered VER 10-3-16 (HL 2650) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Melanoma


CSC MELANOMA INTERFERON ALPHA 2-B (MAINTENANCE) CLINIC ADMINISTERED VER: 10-3-16 – Properties
Pre-Cycle – 11/21/2016 through 11/27/2016 (7 days), Planned
Day 1, Pre-Cycle – Planned for 11/21/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Cycle 1 – 11/28/2016 through 12/25/2016 (28 days), Planned
Day 1, Cycle 1 – Planned for 11/28/2016
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: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 1 of 136
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.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 5 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH; CHEMOTHERAPY
ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 10 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 12 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH; CHEMOTHERAPY
ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 17 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 19 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 2 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH;
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 24 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 26 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) appointments have been scheduled: RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC
(DIFF to done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH; CHEMOTHERAPY ROOM
APPOINTMENT: interferon alpha-2B for 30 minutes.
Day 3, Cycle 1 – Planned for 11/30/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the 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 – Planned for 12/2/2016
Treatment Plan Information
Treatment Plan Summary
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 3 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 1 – Planned for 12/5/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 4 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 10, Cycle 1 – Planned for 12/7/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 5 of 136
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 12, Cycle 1 – Planned for 12/9/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 6 of 136
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 1 – Planned for 12/12/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 7 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 17, Cycle 1 – Planned for 12/14/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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 3:38:11 PM Page 8 of 136
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 19, Cycle 1 – Planned for 12/16/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 1 – Planned for 12/19/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
IV Access
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 9 of 136
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.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 10 of 136
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.
Day 24, Cycle 1 – Planned for 12/21/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 26, Cycle 1 – Planned for 12/23/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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 3:38:11 PM Page 11 of 136
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.
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the 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 – 12/26/2016 through 1/22/2017 (28 days), Planned
Day 1, Cycle 2 – 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: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+3 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+3 Approximate, Expires-S+365, Routine
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 12 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 5 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH; CHEMOTHERAPY
ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 10 FOLLOW-UP
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 13 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 12 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH; CHEMOTHERAPY
ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 17 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 19 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH; CHEMOTHERAPY
ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 24 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 26 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) appointments have been scheduled: RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC
(DIFF to done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH; CHEMOTHERAPY ROOM
APPOINTMENT: interferon alpha-2B for 30 minutes.
Day 3, Cycle 2 – Planned for 12/28/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 14 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the 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 – Planned for 12/30/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 2 – Planned for 1/2/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 15 of 136
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.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 16 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 10, Cycle 2 – Planned for 1/4/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 12, Cycle 2 – Planned for 1/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 17 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 2 – Planned for 1/9/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 18 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 17, Cycle 2 – Planned for 1/11/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 19 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 19, Cycle 2 – Planned for 1/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 20 of 136
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.
Day 22, Cycle 2 – Planned for 1/16/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
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,Andrew [2428787]
11/28/2016 3:38:11 PM Page 21 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 24, Cycle 2 – Planned for 1/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the 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 3:38:11 PM Page 22 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Day 26, Cycle 2 – Planned for 1/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the 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 – 1/23/2017 through 2/19/2017 (28 days), Planned
Day 1, Cycle 3 – Planned for 1/23/2017
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: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 23 of 136
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.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 24 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 5 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH; CHEMOTHERAPY
ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 10 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 12 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH; CHEMOTHERAPY
ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 17 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 19 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH; CHEMOTHERAPY
ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 24 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 26 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) appointments have been scheduled: RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC
(DIFF to done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH; CHEMOTHERAPY ROOM
APPOINTMENT: interferon alpha-2B for 30 minutes.
Day 3, Cycle 3 – Planned for 1/25/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
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,Andrew [2428787]
11/28/2016 3:38:11 PM Page 25 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the 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 – Planned for 1/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 26 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 3 – Planned for 1/30/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
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.
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 27 of 136
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 10, Cycle 3 – Planned for 2/1/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 12, Cycle 3 – Planned for 2/3/2017
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 28 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 3 – Planned for 2/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 29 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 17, Cycle 3 – Planned for 2/8/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 30 of 136
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 19, Cycle 3 – Planned for 2/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
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,Andrew [2428787]
11/28/2016 3:38:11 PM Page 31 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 3 – Planned for 2/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 32 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 24, Cycle 3 – Planned for 2/15/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 33 of 136
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 26, Cycle 3 – Planned for 2/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 – 2/20/2017 through 3/19/2017 (28 days), Planned
Day 1, Cycle 4 – Planned for 2/20/2017
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 34 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+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
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,Andrew [2428787]
11/28/2016 3:38:11 PM Page 35 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 5 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH; CHEMOTHERAPY
ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 10 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 12 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH; CHEMOTHERAPY
ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 17 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 19 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH; CHEMOTHERAPY
ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 24 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 26 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) appointments have been scheduled: RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC
(DIFF to done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH; CHEMOTHERAPY ROOM
APPOINTMENT: interferon alpha-2B for 30 minutes.
Day 3, Cycle 4 – Planned for 2/22/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
IV Access
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 36 of 136
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the 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 – Planned for 2/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
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,Andrew [2428787]
11/28/2016 3:38:11 PM Page 37 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 4 – Planned for 2/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 38 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 10, Cycle 4 – Planned for 3/1/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 39 of 136
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 12, Cycle 4 – Planned for 3/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 4 – Planned for 3/6/2017
Treatment Plan Information
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 40 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2
subcutaneous three times weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12
cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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.
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 41 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 17, Cycle 4 – Planned for 3/8/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 19, Cycle 4 – Planned for 3/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
IV Access
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 42 of 136
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 4 – Planned for 3/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 43 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 24, Cycle 4 – Planned for 3/15/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 44 of 136
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 26, Cycle 4 – Planned for 3/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 45 of 136
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 – 3/20/2017 through 4/16/2017 (28 days), Planned
Day 1, Cycle 5 – Planned for 3/20/2017
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: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+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
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 46 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 5 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH; CHEMOTHERAPY
ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 10 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 12 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH; CHEMOTHERAPY
ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 17 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 19 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH; CHEMOTHERAPY
ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 47 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DAY 24 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 26 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) appointments have been scheduled: RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC
(DIFF to done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH; CHEMOTHERAPY ROOM
APPOINTMENT: interferon alpha-2B for 30 minutes.
Day 3, Cycle 5 – Planned for 3/22/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the 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 5 – Planned for 3/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
IV Access
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 48 of 136
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 5 – Planned for 3/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 49 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 10, Cycle 5 – Planned for 3/29/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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 3:38:11 PM Page 50 of 136
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 12, Cycle 5 – Planned for 3/31/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 51 of 136
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 5 – Planned for 4/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 52 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 17, Cycle 5 – Planned for 4/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 53 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 19, Cycle 5 – Planned for 4/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 5 – Planned for 4/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 54 of 136
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.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 55 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 24, Cycle 5 – Planned for 4/12/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 26, Cycle 5 – Planned for 4/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 56 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 6 – 4/17/2017 through 5/14/2017 (28 days), Planned
Day 1, Cycle 6 – Planned for 4/17/2017
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: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+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
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 57 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 5 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH; CHEMOTHERAPY
ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 10 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 12 FOLLOW-UP
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 58 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH; CHEMOTHERAPY
ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 17 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 19 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH; CHEMOTHERAPY
ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 24 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 26 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) appointments have been scheduled: RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC
(DIFF to done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH; CHEMOTHERAPY ROOM
APPOINTMENT: interferon alpha-2B for 30 minutes.
Day 3, Cycle 6 – Planned for 4/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 59 of 136
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.
Day 5, Cycle 6 – Planned for 4/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 6 – Planned for 4/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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 3:38:11 PM Page 60 of 136
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the 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 3:38:11 PM Page 61 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Day 10, Cycle 6 – Planned for 4/26/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 12, Cycle 6 – Planned for 4/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 62 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 6 – Planned for 5/1/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 63 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 17, Cycle 6 – Planned for 5/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 64 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 19, Cycle 6 – Planned for 5/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the 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 3:38:11 PM Page 65 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Day 22, Cycle 6 – Planned for 5/8/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 66 of 136
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 24, Cycle 6 – Planned for 5/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 26, Cycle 6 – Planned for 5/12/2017
Treatment Plan Information
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 67 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2
subcutaneous three times weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12
cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 7 – 5/15/2017 through 6/11/2017 (28 days), Planned
Day 1, Cycle 7 – Planned for 5/15/2017
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: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 68 of 136
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.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 69 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 5 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH; CHEMOTHERAPY
ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 10 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 12 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH; CHEMOTHERAPY
ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 17 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 19 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH; CHEMOTHERAPY
ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 24 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 26 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) appointments have been scheduled: RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC
(DIFF to done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH; CHEMOTHERAPY ROOM
APPOINTMENT: interferon alpha-2B for 30 minutes.
Day 3, Cycle 7 – Planned for 5/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
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,Andrew [2428787]
11/28/2016 3:38:11 PM Page 70 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the 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 7 – Planned for 5/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the 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 3:38:11 PM Page 71 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Day 8, Cycle 7 – Planned for 5/22/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 72 of 136
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 10, Cycle 7 – Planned for 5/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 12, Cycle 7 – Planned for 5/26/2017
Treatment Plan Information
Treatment Plan Summary
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 73 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 7 – Planned for 5/29/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 74 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 17, Cycle 7 – Planned for 5/31/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 75 of 136
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 19, Cycle 7 – Planned for 6/2/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 76 of 136
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 7 – Planned for 6/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 77 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 24, Cycle 7 – Planned for 6/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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 3:38:11 PM Page 78 of 136
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 26, Cycle 7 – Planned for 6/9/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 8 – 6/12/2017 through 7/9/2017 (28 days), Planned
Day 1, Cycle 8 – Planned for 6/12/2017
Treatment Plan Information
Reference Information (1)
MELANOMA: Kirkwood et al. J Clin Oncol 1996;14(1):7-17.
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 79 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Reference Information (2)
MELANOMA: Moschos SJ et al. J Clin Oncol 2004(1);22:11-3.
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+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
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.
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 80 of 136
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 5 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH; CHEMOTHERAPY
ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 10 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 12 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH; CHEMOTHERAPY
ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 17 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 19 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH; CHEMOTHERAPY
ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 24 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 26 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) appointments have been scheduled: RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC
(DIFF to done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH; CHEMOTHERAPY ROOM
APPOINTMENT: interferon alpha-2B for 30 minutes.
Day 3, Cycle 8 – Planned for 6/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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 3:38:11 PM Page 81 of 136
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the 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 8 – Planned for 6/16/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 82 of 136
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 8 – Planned for 6/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 83 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 10, Cycle 8 – Planned for 6/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 84 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 12, Cycle 8 – Planned for 6/23/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 8 – Planned for 6/26/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 85 of 136
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.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 86 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 17, Cycle 8 – Planned for 6/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 19, Cycle 8 – Planned for 6/30/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 87 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 8 – Planned for 7/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 88 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 24, Cycle 8 – Planned for 7/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 89 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 26, Cycle 8 – Planned for 7/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 90 of 136
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 9 – 7/10/2017 through 8/6/2017 (28 days), Planned
Day 1, Cycle 9 – Planned for 7/10/2017
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: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+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 3:38:11 PM Page 91 of 136
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.
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 5 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH; CHEMOTHERAPY
ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 10 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 12 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH; CHEMOTHERAPY
ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 17 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 19 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH; CHEMOTHERAPY
ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 24 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 26 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 29 FOLLOW-UP
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 92 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

(Day 1 of next cycle) appointments have been scheduled: RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC
(DIFF to done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH; CHEMOTHERAPY ROOM
APPOINTMENT: interferon alpha-2B for 30 minutes.
Day 3, Cycle 9 – Planned for 7/12/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the 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 9 – Planned for 7/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 93 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 9 – Planned for 7/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 94 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 10, Cycle 9 – Planned for 7/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 95 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 12, Cycle 9 – Planned for 7/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 96 of 136
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.
Day 15, Cycle 9 – Planned for 7/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
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,Andrew [2428787]
11/28/2016 3:38:11 PM Page 97 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 17, Cycle 9 – Planned for 7/26/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the 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 3:38:11 PM Page 98 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Day 19, Cycle 9 – Planned for 7/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 9 – Planned for 7/31/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 99 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 24, Cycle 9 – Planned for 8/2/2017
Treatment Plan Information
Treatment Plan Summary
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 100 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 26, Cycle 9 – Planned for 8/4/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 101 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 10 – 8/7/2017 through 9/3/2017 (28 days), Planned
Day 1, Cycle 10 – Planned for 8/7/2017
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: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+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
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 102 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 5 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH; CHEMOTHERAPY
ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 10 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 12 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH; CHEMOTHERAPY
ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 17 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 103 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DAY 19 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH; CHEMOTHERAPY
ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 24 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 26 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) appointments have been scheduled: RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC
(DIFF to done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH; CHEMOTHERAPY ROOM
APPOINTMENT: interferon alpha-2B for 30 minutes.
Day 3, Cycle 10 – Planned for 8/9/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the 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 10 – Planned for 8/11/2017
Treatment Plan Information
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 104 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 10 – Planned for 8/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 105 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 10, Cycle 10 – Planned for 8/16/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 106 of 136
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 12, Cycle 10 – Planned for 8/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
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,Andrew [2428787]
11/28/2016 3:38:11 PM Page 107 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 10 – Planned for 8/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 108 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 17, Cycle 10 – Planned for 8/23/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 109 of 136
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 19, Cycle 10 – Planned for 8/25/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 10 – Planned for 8/28/2017
Treatment Plan Information
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 110 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2
subcutaneous three times weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12
cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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.
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 111 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 24, Cycle 10 – Planned for 8/30/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 26, Cycle 10 – Planned for 9/1/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
IV Access
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 112 of 136
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 11 – 9/4/2017 through 10/1/2017 (28 days), Planned
Day 1, Cycle 11 – Planned for 9/4/2017
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: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 113 of 136
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 114 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DAY 5 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH; CHEMOTHERAPY
ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 10 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 12 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH; CHEMOTHERAPY
ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 17 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 19 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH; CHEMOTHERAPY
ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 24 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 26 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) appointments have been scheduled: RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC
(DIFF to done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH; CHEMOTHERAPY ROOM
APPOINTMENT: interferon alpha-2B for 30 minutes.
Day 3, Cycle 11 – Planned for 9/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 115 of 136
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the 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 11 – Planned for 9/8/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 11 – Planned for 9/11/2017
Treatment Plan Information
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 116 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2
subcutaneous three times weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12
cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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.
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 117 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Medications
interferon alfa-2B (INTRON A) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 10, Cycle 11 – Planned for 9/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 12, Cycle 11 – Planned for 9/15/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
IV Access
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 118 of 136
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 11 – Planned for 9/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 119 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 17, Cycle 11 – Planned for 9/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 120 of 136
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 19, Cycle 11 – Planned for 9/22/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 121 of 136
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 11 – Planned for 9/25/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 122 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 24, Cycle 11 – Planned for 9/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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 3:38:11 PM Page 123 of 136
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 26, Cycle 11 – Planned for 9/29/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 12 – 10/2/2017 through 10/29/2017 (28 days), Planned
Day 1, Cycle 12 – Planned for 10/2/2017
Treatment Plan Information
Reference Information (1)
MELANOMA: Kirkwood et al. J Clin Oncol 1996;14(1):7-17.
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 124 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Reference Information (2)
MELANOMA: Moschos SJ et al. J Clin Oncol 2004(1);22:11-3.
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+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
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.
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 125 of 136
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 5 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH; CHEMOTHERAPY
ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 10 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 12 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH; CHEMOTHERAPY
ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 17 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 19 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 22 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH; CHEMOTHERAPY
ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 24 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 26 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: interferon alpha-2B for 30 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) appointments have been scheduled: RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC
(DIFF to done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH; CHEMOTHERAPY ROOM
APPOINTMENT: interferon alpha-2B for 30 minutes.
Day 3, Cycle 12 – Planned for 10/4/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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 3:38:11 PM Page 126 of 136
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the 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 12 – Planned for 10/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 127 of 136
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 8, Cycle 12 – Planned for 10/9/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 128 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 10, Cycle 12 – Planned for 10/11/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 129 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 12, Cycle 12 – Planned for 10/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 12 – Planned for 10/16/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 130 of 136
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.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 131 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 17, Cycle 12 – Planned for 10/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 19, Cycle 12 – Planned for 10/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 132 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 12 – Planned for 10/23/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 133 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 24, Cycle 12 – Planned for 10/25/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 134 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 26, Cycle 12 – Planned for 10/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (clinic administration); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
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
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
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) 50000000 UNIT/ML injection 18 Million Units
18 Million Units (rounded from 17.9 Million Units = 10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight),
Subcutaneous, ONCE, 1 dose Starting when released
Corticosteroids are NOT allowed for routine use. Round to the nearest 1 million units.
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 135 of 136
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.
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ZZtestonc,Andrew [2428787]
11/28/2016 3:38:11 PM Page 136 of 136
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org