/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-96986-en.cckm

201611333

page

100

UWHC,UWMF,

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

CSC Melanoma Pembrolizumab(21D:1) VER 10-3-16 (HL 5196)

CSC Melanoma Pembrolizumab(21D:1) VER 10-3-16 (HL 5196) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Melanoma


CSC MELANOMA PEMBROLIZUMAB (21D:1) 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 (Advanced/Metastatic); THERAPY: pembrolizumab 2 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE:
until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S Approximate, Expires-S+365, Routine
BUN
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
CALCIUM
Expected-S Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S Approximate, Expires-S+365, Routine
PROTEIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S Approximate, Expires-S+365, Routine
LIPASE
Expected-S Approximate, Expires-S+365, Routine
AMYLASE
Expected-S Approximate, Expires-S+365, Routine
TSH
Expected-S Approximate, Expires-S+365, Routine
Baseline and prior to every EVEN Cycle only.
T4, FREE
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ZZtestonc,Andrew [2428787]
11/28/2016 3:51:42 PM Page 1 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Expected-S Approximate, Expires-S+365, Routine
Baseline and prior to every EVEN Cycle only.
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE
Expected-S Approximate, Expires-S+365, Routine
Take Home Medications
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed., 8 mg, Disp-30 tab, R-5, EVERY 8 HOURS PRN starting S, Local Printer
Cycle 1 – 11/28/2016 through 12/18/2016 (21 days), Planned
Day 1, Cycle 1 – Planned for 11/28/2016
Treatment Plan Information
Reference Information (1)
MELANOMA (ADVANCED/METASTATIC): Robert C, et al. Lancet 2014 Jul 15. pii: S0140-6736(14)60958-2. doi:10.1016/S0140-
6736(14)60958-2. [Epub ahead of print]
Treatment Plan Summary
DISEASE: Melanoma (Advanced/Metastatic); THERAPY: pembrolizumab 2 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE:
until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to pembrolizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications. Patient must be monitored for 30 minutes after first dose of pembrolizumab.
Monitoring Parameters (1)
Notify MD for Systolic Blood Pressure below 100 mmHg (if below pre-infusion Blood Pressure) or for any symptoms of hypotension.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor Blood Pressure, Heart Rate, Temperature, Respiratory Rate and Pain Level every 15 minutes during pembrolizumab
infusion. Also monitor blood pressure, heart rate, temperature, respiratory rate and pain level 30 minutes after first pembrolizumab
dose.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
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ZZtestonc,Andrew [2428787]
11/28/2016 3:51:42 PM Page 2 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
pembrolizumab (KEYTRUDA) 140 mg in sodium chloride 0.9 % 50 mL bag
140 mg (2 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer IV over 30 minutes through an intravenous line containing a sterile, non-pyrogenic, low-protein binding 0.22 micron in-line
filter. Do not co-administer other drugs through same infusion line. Hypersensitivity reaction to pembrolizumab can occur. For first
and second dose, patient should be treated in a location to optimize emergency care. See Emergency Medications. Patient must be
monitored for 30 minutes after first dose of pembrolizumab.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose, BUN,
Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, LDH, Lipase, Amylase; LABS (prior to
every EVEN Cycle only): TSH and Free T4; CHEMOTHERAPY ROOM APPOINTMENT: pembrolizumab for 60 minutes.
Cycle 2 – 12/19/2016 through 1/8/2017 (21 days), Planned
Day 1, Cycle 2 – Planned for 12/19/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Advanced/Metastatic); THERAPY: pembrolizumab 2 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE:
until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+21 Approximate, Expires-S+365, Routine
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ZZtestonc,Andrew [2428787]
11/28/2016 3:51:42 PM Page 3 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

GLUCOSE
Expected-S+21 Approximate, Expires-S+365, Routine
BUN
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+21 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+21 Approximate, Expires-S+365, Routine
PROTEIN, TOTAL
Expected-S+21, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+21 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+21 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
LIPASE
Expected-S+21, Expires-S+365, Routine
AMYLASE
Expected-S+21, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
TSH
Expected-S+21 Approximate, Expires-S+365, Routine
Baseline and prior to every EVEN Cycle only.
T4, FREE
Expected-S+21 Approximate, Expires-S+365, Routine
Baseline and prior to every EVEN Cycle only.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to pembrolizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications. Patient must be monitored for 30 minutes after first dose of pembrolizumab.
Monitoring Parameters (1)
Notify MD for Systolic Blood Pressure below 100 mmHg (if below pre-infusion Blood Pressure) or for any symptoms of hypotension.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor Blood Pressure, Heart Rate, Temperature, Respiratory Rate and Pain Level every 15 minutes during pembrolizumab
infusion. Also monitor blood pressure, heart rate, temperature, respiratory rate and pain level 30 minutes after first pembrolizumab
dose.
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 3:51:42 PM Page 4 of 14
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
pembrolizumab (KEYTRUDA) 140 mg in sodium chloride 0.9 % 50 mL bag
140 mg (2 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer IV over 30 minutes through an intravenous line containing a sterile, non-pyrogenic, low-protein binding 0.22 micron in-line
filter. Do not co-administer other drugs through same infusion line. Hypersensitivity reaction to pembrolizumab can occur. For first
and second dose, patient should be treated in a location to optimize emergency care. See Emergency Medications. Patient must be
monitored for 30 minutes after first dose of pembrolizumab.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose, BUN,
Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, LDH, Lipase, Amylase; LABS (prior to
every EVEN Cycle only): TSH and Free T4; CHEMOTHERAPY ROOM APPOINTMENT: pembrolizumab for 60 minutes.
Cycle 3 – 1/9/2017 through 1/29/2017 (21 days), Planned
Day 1, Cycle 3 – Planned for 1/9/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Advanced/Metastatic); THERAPY: pembrolizumab 2 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE:
until disease progression.
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 3:51:42 PM Page 5 of 14
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 WITH DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+21 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+21 Approximate, Expires-S+365, Routine
BUN
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+21 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+21 Approximate, Expires-S+365, Routine
PROTEIN, TOTAL
Expected-S+21, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+21 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+21 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
LIPASE
Expected-S+21, Expires-S+365, Routine
AMYLASE
Expected-S+21, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
TSH
Expected-S+21 Approximate, Expires-S+365, Routine
Baseline and prior to every EVEN Cycle only.
T4, FREE
Expected-S+21 Approximate, Expires-S+365, Routine
Baseline and prior to every EVEN Cycle only.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to pembrolizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications. Patient must be monitored for 30 minutes after first dose of pembrolizumab.
Monitoring Parameters (1)
Notify MD for Systolic Blood Pressure below 100 mmHg (if below pre-infusion Blood Pressure) or for any symptoms of hypotension.
Vital Signs
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ZZtestonc,Andrew [2428787]
11/28/2016 3:51:42 PM Page 6 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

SEE COMMENTS Starting when released Until Specified
Monitor Blood Pressure, Heart Rate, Temperature, Respiratory Rate and Pain Level every 15 minutes during pembrolizumab
infusion. Also monitor blood pressure, heart rate, temperature, respiratory rate and pain level 30 minutes after first pembrolizumab
dose.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
pembrolizumab (KEYTRUDA) 140 mg in sodium chloride 0.9 % 50 mL bag
140 mg (2 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer IV over 30 minutes through an intravenous line containing a sterile, non-pyrogenic, low-protein binding 0.22 micron in-line
filter. Do not co-administer other drugs through same infusion line. Hypersensitivity reaction to pembrolizumab can occur. For first
and second dose, patient should be treated in a location to optimize emergency care. See Emergency Medications. Patient must be
monitored for 30 minutes after first dose of pembrolizumab.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose, BUN,
Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, LDH, Lipase, Amylase; LABS (prior to
every EVEN Cycle only): TSH and Free T4; CHEMOTHERAPY ROOM APPOINTMENT: pembrolizumab for 60 minutes.
Cycle 4 – 1/30/2017 through 2/19/2017 (21 days), Planned
Day 1, Cycle 4 – Planned for 1/30/2017
Treatment Plan Information
Treatment Plan Summary
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ZZtestonc,Andrew [2428787]
11/28/2016 3:51:42 PM Page 7 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DISEASE: Melanoma (Advanced/Metastatic); THERAPY: pembrolizumab 2 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE:
until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+21 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+21 Approximate, Expires-S+365, Routine
BUN
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+21 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+21 Approximate, Expires-S+365, Routine
PROTEIN, TOTAL
Expected-S+21, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+21 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+21 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
LIPASE
Expected-S+21, Expires-S+365, Routine
AMYLASE
Expected-S+21, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
TSH
Expected-S+21 Approximate, Expires-S+365, Routine
Baseline and prior to every EVEN Cycle only.
T4, FREE
Expected-S+21 Approximate, Expires-S+365, Routine
Baseline and prior to every EVEN Cycle only.
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ZZtestonc,Andrew [2428787]
11/28/2016 3:51:42 PM Page 8 of 14
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
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to pembrolizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications. Patient must be monitored for 30 minutes after first dose of pembrolizumab.
Monitoring Parameters (1)
Notify MD for Systolic Blood Pressure below 100 mmHg (if below pre-infusion Blood Pressure) or for any symptoms of hypotension.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor Blood Pressure, Heart Rate, Temperature, Respiratory Rate and Pain Level every 15 minutes during pembrolizumab
infusion. Also monitor blood pressure, heart rate, temperature, respiratory rate and pain level 30 minutes after first pembrolizumab
dose.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
pembrolizumab (KEYTRUDA) 140 mg in sodium chloride 0.9 % 50 mL bag
140 mg (2 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer IV over 30 minutes through an intravenous line containing a sterile, non-pyrogenic, low-protein binding 0.22 micron in-line
filter. Do not co-administer other drugs through same infusion line. Hypersensitivity reaction to pembrolizumab can occur. For first
and second dose, patient should be treated in a location to optimize emergency care. See Emergency Medications. Patient must be
monitored for 30 minutes after first dose of pembrolizumab.
Follow-Up
DAY 22 FOLLOW-UP
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ZZtestonc,Andrew [2428787]
11/28/2016 3:51:42 PM Page 9 of 14
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) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose, BUN,
Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, LDH, Lipase, Amylase; LABS (prior to
every EVEN Cycle only): TSH and Free T4; CHEMOTHERAPY ROOM APPOINTMENT: pembrolizumab for 60 minutes.
Cycle 5 – 2/20/2017 through 3/12/2017 (21 days), Planned
Day 1, Cycle 5 – Planned for 2/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Advanced/Metastatic); THERAPY: pembrolizumab 2 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE:
until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+21 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+21 Approximate, Expires-S+365, Routine
BUN
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+21 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+21 Approximate, Expires-S+365, Routine
PROTEIN, TOTAL
Expected-S+21, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+21 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+21 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
LIPASE
Expected-S+21, Expires-S+365, Routine
AMYLASE
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ZZtestonc,Andrew [2428787]
11/28/2016 3:51:42 PM Page 10 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Expected-S+21, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
TSH
Expected-S+21 Approximate, Expires-S+365, Routine
Baseline and prior to every EVEN Cycle only.
T4, FREE
Expected-S+21 Approximate, Expires-S+365, Routine
Baseline and prior to every EVEN Cycle only.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to pembrolizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications. Patient must be monitored for 30 minutes after first dose of pembrolizumab.
Monitoring Parameters (1)
Notify MD for Systolic Blood Pressure below 100 mmHg (if below pre-infusion Blood Pressure) or for any symptoms of hypotension.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor Blood Pressure, Heart Rate, Temperature, Respiratory Rate and Pain Level every 15 minutes during pembrolizumab
infusion. Also monitor blood pressure, heart rate, temperature, respiratory rate and pain level 30 minutes after first pembrolizumab
dose.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
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ZZtestonc,Andrew [2428787]
11/28/2016 3:51:42 PM Page 11 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

pembrolizumab (KEYTRUDA) 140 mg in sodium chloride 0.9 % 50 mL bag
140 mg (2 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer IV over 30 minutes through an intravenous line containing a sterile, non-pyrogenic, low-protein binding
0.22 micron in-line filter. Do not co-administer other drugs through same infusion line. Hypersensitivity reaction to
pembrolizumab can occur. For first and second dose, patient should be treated in a location to optimize emergency
care. See Emergency Medications. Patient must be monitored for 30 minutes after first dose of pembrolizumab.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose, BUN,
Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, LDH, Lipase, Amylase; LABS (prior to
every EVEN Cycle only): TSH and Free T4; CHEMOTHERAPY ROOM APPOINTMENT: pembrolizumab for 60 minutes.
Cycle 6 – 3/13/2017 through 4/2/2017 (21 days), Planned
Day 1, Cycle 6 – Planned for 3/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Advanced/Metastatic); THERAPY: pembrolizumab 2 mg/kg IV Day 1; CYCLE LENGTH: 21 days; COURSE:
until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+21 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+21 Approximate, Expires-S+365, Routine
BUN
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+21 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+21 Approximate, Expires-S+365, Routine
PROTEIN, TOTAL
Expected-S+21, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+21 Approximate, Expires-S+365, Routine
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ZZtestonc,Andrew [2428787]
11/28/2016 3:51:42 PM Page 12 of 14
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+21 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
LIPASE
Expected-S+21, Expires-S+365, Routine
AMYLASE
Expected-S+21, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
TSH
Expected-S+21 Approximate, Expires-S+365, Routine
Baseline and prior to every EVEN Cycle only.
T4, FREE
Expected-S+21 Approximate, Expires-S+365, Routine
Baseline and prior to every EVEN Cycle only.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to pembrolizumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications. Patient must be monitored for 30 minutes after first dose of pembrolizumab.
Monitoring Parameters (1)
Notify MD for Systolic Blood Pressure below 100 mmHg (if below pre-infusion Blood Pressure) or for any symptoms of hypotension.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor Blood Pressure, Heart Rate, Temperature, Respiratory Rate and Pain Level every 15 minutes during pembrolizumab
infusion. Also monitor blood pressure, heart rate, temperature, respiratory rate and pain level 30 minutes after first pembrolizumab
dose.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
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ZZtestonc,Andrew [2428787]
11/28/2016 3:51:42 PM Page 13 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
pembrolizumab (KEYTRUDA) 140 mg in sodium chloride 0.9 % 50 mL bag
140 mg (2 mg/kg × 70 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer IV over 30 minutes through an intravenous line containing a sterile, non-pyrogenic, low-protein binding 0.22 micron in-line
filter. Do not co-administer other drugs through same infusion line. Hypersensitivity reaction to pembrolizumab can occur. For first
and second dose, patient should be treated in a location to optimize emergency care. See Emergency Medications. Patient must be
monitored for 30 minutes after first dose of pembrolizumab.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose, BUN,
Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, LDH, Lipase, Amylase; LABS (prior to
every EVEN Cycle only): TSH and Free T4; CHEMOTHERAPY ROOM APPOINTMENT: pembrolizumab for 60 minutes.
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ZZtestonc,Andrew [2428787]
11/28/2016 3:51:42 PM Page 14 of 14
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org