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

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20180122

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UWHC,UWMF,

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

CSC Melanoma Nivolumab(28D:1,15) VER 1-16-18 (HL 5361)

CSC Melanoma Nivolumab(28D:1,15) VER 1-16-18 (HL 5361) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Melanoma


CSC MELANOMA NIVOLUMAB (28D:1,15) VER: 1-16-18 –  Properties
Pre-Cycle –  1/9/2018 through 1/15/2018 (7 days), Planned
Day 1, Pre-Cycle –  Planned for 1/9/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Advanced/Metastatic); THERAPY: nivolumab 3 mg/kg IV Day 1 and 15 (maximum dose = 240 mg);
CYCLE LENGTH: 28 days; COURSE: until disease progression.
Treatment Plan Summary (2)
DISEASE: Melanoma (Adjuvant for resected high risk patients); THERAPY: nivolumab 3 mg/kg IV Day 1 and 15
(maximum dose = 240 mg); CYCLE LENGTH: 28 days; COURSE: up to 1 year.
NOTE: High risk definition per study eligibility criteria, (2009 AJCC (seventh edition)) including: stage IIIB, IIIC, or IV
melanoma and histologically confirmed melanoma with metastases to regional lymph nodes or distant metastases that
had been surgically resected (patients with prior systemic therapy for melanoma excluded). Post surgical patients
should begin nivolumab therapy approximately 12 weeks after surgery unless adjuvant XRT is required.  Post surgical
patients requiring adjuvant XRT should begin nivolumab therapy approximately 14 to 16 weeks after surgery.
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+397, Routine
GLUCOSE
Expected: S Approximate, Expires: S+397, Routine
BUN
Expected: S Approximate, Expires: S+397, Routine
CREATININE
Expected: S Approximate, Expires: S+397, Routine
CALCIUM
Expected: S Approximate, Expires: S+397, Routine
ALBUMIN
Expected: S Approximate, Expires: S+397, Routine
PROTEIN, TOTAL
Expected: S Approximate, Expires: S+397, Routine
BILIRUBIN, TOTAL
Expected: S Approximate, Expires: S+397, Routine
AST/SGOT
Expected: S Approximate, Expires: S+397, Routine
ALT/SGPT
Expected: S Approximate, Expires: S+397, Routine
ALKALINE PHOSPHATASE
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ZZtestonc,Diane D [2466374]
1/16/2018 9:01:40 AM Page 1 of 11
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Expected: S Approximate, Expires: S+397, Routine
LD, TOTAL
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
Expected: S Approximate, Expires: S+365, Routine
Baseline and prior to every EVEN Cycle only.
LIPASE
Expected: S Approximate, Expires: S+365, Routine
AMYLASE
Expected: S Approximate, Expires: S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE, URINE
Expected: S Approximate, Expires: S+122, Routine
Take Home Medications
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed for nausea/vomiting., 8 mg, Disp-30 tab, R-5, EVERY 8 HOURS PRN
starting S, Local Printer
prochlorperazine (COMPAZINE) 10 MG tab
Allergy/Contraindication: Promethazine Hcl Reactions: Vomiting
Take 1 tab by mouth every 6 hours as needed for nausea/vomiting., 10 mg, Disp-30 tab, R-5, EVERY 6 HOURS PRN
starting S, Local Printer
Cycle 1 –  1/16/2018 through 2/12/2018 (28 days), Planned
Day 1, Cycle 1 –  Planned for 1/16/2018
Treatment Plan Information
Reference Information (1)
MELANOMA (Advanced/Metastatic): Weber JS, et al. Lancet Oncol 2015;16:375-84.
Reference Information (2)
MELANOMA (Advanced/Metastatic): Robert C, et al. N Engl J Med 2015;372(4):320-30.
Reference Information (3)
MELANOMA: (Adjuvant): Weber J, et al. N Engl J Med 2017;377(19):1824-35
Reference Information (4)
MELANOMA: http://www.fda.gov/Drugs/InformationOnDrugs/ApprovedDrugs/ucm520871.htm. Accessed December
19, 2016.
Treatment Plan Summary
DISEASE: Melanoma (Advanced/Metastatic); THERAPY: nivolumab 3 mg/kg IV Day 1 and 15 (maximum dose = 240 mg);
CYCLE LENGTH: 28 days; COURSE: until disease progression.
Treatment Plan Summary (2)
DISEASE: Melanoma (Adjuvant for resected high risk patients); THERAPY: nivolumab 3 mg/kg IV Day 1 and 15
(maximum dose = 240 mg); CYCLE LENGTH: 28 days; COURSE: up to 1 year.
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ZZtestonc,Diane D [2466374]
1/16/2018 9:01:40 AM Page 2 of 11
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

NOTE: High risk definition per study eligibility criteria, (2009 AJCC (seventh edition)) including: stage IIIB, IIIC, or IV
melanoma and histologically confirmed melanoma with metastases to regional lymph nodes or distant metastases that
had been surgically resected (patients with prior systemic therapy for melanoma excluded). Post surgical patients
should begin nivolumab therapy approximately 12 weeks after surgery unless adjuvant XRT is required.  Post surgical
patients requiring adjuvant XRT should begin nivolumab therapy approximately 14 to 16 weeks after surgery.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Creatinine, AST, ALT, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for Creatinine greater than 1.5 X ULN or AST greater than 3 X ULN or ALT greater
than 3 X ULN or Total Bilirubin greater than 1.5 X ULN .
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to nivolumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Patient Instructions(1)
Advise patients to contact provider right away with signs of pneumonitis (new or worse cough, chest pain or shortness
of breath) or colitis (abdominal pain; mucus or blood in stool).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
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ZZtestonc,Diane D [2466374]
1/16/2018 9:01:40 AM Page 3 of 11
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

famotidine (PEPCID) injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
nivolumab (OPDIVO) 3 mg/kg in sodium chloride 0.9 % 100 mL bag
3 mg/kg, Intravenous, ONCE, 1 dose Starting when released, Administer over 30 Minutes
Maximum dose = 240 mg. Administer with low protein binding in line 0.2 or 0.22 micron filter over 30 minutes. Do not
shake. Do not co-administer other drugs through same infusion line. Hypersensitivity reaction to nivolumab can occur.
For first and second dose, patient should be treated in a location to optimize emergency care. See Emergency
Medications.
Follow-Up
DAY 15 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Calcium,
Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Lipase, Amylase, LDH; CHEMOTHERAPY ROOM
APPOINTMENT: nivolumab for 60 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose,
BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Lipase, Amylase, LDH;
LABS (prior to every EVEN Cycle only): TSH and Free T4; CHEMOTHERAPY ROOM APPOINTMENT: nivolumab for 60
minutes.
Day 15, Cycle 1 –  Planned for 1/30/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Advanced/Metastatic); THERAPY: nivolumab 3 mg/kg IV Day 1 and 15 (maximum dose = 240 mg);
CYCLE LENGTH: 28 days; COURSE: until disease progression.
Treatment Plan Summary (2)
DISEASE: Melanoma (Adjuvant for resected high risk patients); THERAPY: nivolumab 3 mg/kg IV Day 1 and 15
(maximum dose = 240 mg); CYCLE LENGTH: 28 days; COURSE: up to 1 year.
NOTE: High risk definition per study eligibility criteria, (2009 AJCC (seventh edition)) including: stage IIIB, IIIC, or IV
melanoma and histologically confirmed melanoma with metastases to regional lymph nodes or distant metastases that
had been surgically resected (patients with prior systemic therapy for melanoma excluded). Post surgical patients
should begin nivolumab therapy approximately 12 weeks after surgery unless adjuvant XRT is required.  Post surgical
patients requiring adjuvant XRT should begin nivolumab therapy approximately 14 to 16 weeks after surgery.
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+14 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
GLUCOSE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
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ZZtestonc,Diane D [2466374]
1/16/2018 9:01:40 AM Page 4 of 11
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

BUN
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
CALCIUM
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALBUMIN
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
PROTEIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
LIPASE
Expected: S+14 Approximate, Expires: S+365, Routine
AMYLASE
Expected: S+14 Approximate, Expires: S+365, Routine
LD, TOTAL
Expected: S+14 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Creatinine, AST, ALT, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for Creatinine greater than 1.5 X ULN or greater than 1.5 X baseline or AST
greater than 3 X ULN or ALT greater than 3 X ULN or Total Bilirubin greater than 1.5 X ULN .
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to nivolumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Patient Instructions(1)
Advise patients to contact provider right away with signs of pneumonitis (new or worse cough, chest pain or shortness
of breath) or colitis (abdominal pain; mucus or blood in stool).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
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ZZtestonc,Diane D [2466374]
1/16/2018 9:01:40 AM Page 5 of 11
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@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
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine (PEPCID) injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
nivolumab (OPDIVO) 3 mg/kg in sodium chloride 0.9 % 100 mL bag
3 mg/kg, Intravenous, ONCE, 1 dose Starting when released, Administer over 30 Minutes
Maximum dose = 240 mg. Administer with low protein binding in line 0.2 or 0.22 micron filter over 30 minutes. Do not
shake. Do not co-administer other drugs through same infusion line. Hypersensitivity reaction to nivolumab can occur.
For first and second dose, patient should be treated in a location to optimize emergency care. See Emergency
Medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 –  2/13/2018 through 3/12/2018 (28 days), Planned
Day 1, Cycle 2 –  Planned for 2/13/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Advanced/Metastatic); THERAPY: nivolumab 3 mg/kg IV Day 1 and 15 (maximum dose = 240 mg);
CYCLE LENGTH: 28 days; COURSE: until disease progression.
Treatment Plan Summary (2)
DISEASE: Melanoma (Adjuvant for resected high risk patients); THERAPY: nivolumab 3 mg/kg IV Day 1 and 15
(maximum dose = 240 mg); CYCLE LENGTH: 28 days; COURSE: up to 1 year.
NOTE: High risk definition per study eligibility criteria, (2009 AJCC (seventh edition)) including: stage IIIB, IIIC, or IV
melanoma and histologically confirmed melanoma with metastases to regional lymph nodes or distant metastases that
had been surgically resected (patients with prior systemic therapy for melanoma excluded). Post surgical patients
should begin nivolumab therapy approximately 12 weeks after surgery unless adjuvant XRT is required.  Post surgical
patients requiring adjuvant XRT should begin nivolumab therapy approximately 14 to 16 weeks after surgery.
Consent
Verify Consent
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ZZtestonc,Diane D [2466374]
1/16/2018 9:01:40 AM Page 6 of 11
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

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+14 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
GLUCOSE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
BUN
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
CALCIUM
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALBUMIN
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
PROTEIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
LIPASE
Expected: S+14 Approximate, Expires: S+365, Routine
AMYLASE
Expected: S+14 Approximate, Expires: S+365, Routine
LD, TOTAL
Expected: S+14 Approximate, Expires: S+365, Routine
Pre-Labs (delete all that do not apply)
TSH
Expected: S+14 Approximate, Expires: S+365, Routine
Baseline and prior to every EVEN Cycle only.
T4, FREE
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ZZtestonc,Diane D [2466374]
1/16/2018 9:01:40 AM Page 7 of 11
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Expected: S+14 Approximate, Expires: S+365, Routine
Baseline and prior to every EVEN Cycle only.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Creatinine, AST, ALT, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for Creatinine greater than 1.5 X ULN or greater than 1.5 X baseline or AST
greater than 3 X ULN or ALT greater than 3 X ULN or Total Bilirubin greater than 1.5 X ULN .
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to nivolumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Patient Instructions(1)
Advise patients to contact provider right away with signs of pneumonitis (new or worse cough, chest pain or shortness
of breath) or colitis (abdominal pain; mucus or blood in stool).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine (PEPCID) injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
nivolumab (OPDIVO) 3 mg/kg in sodium chloride 0.9 % 100 mL bag
3 mg/kg, Intravenous, ONCE, 1 dose Starting when released, Administer over 30 Minutes
Maximum dose = 240 mg. Administer with low protein binding in line 0.2 or 0.22 micron filter over 30 minutes. Do not
shake. Do not co-administer other drugs through same infusion line. Hypersensitivity reaction to nivolumab can occur.
For first and second dose, patient should be treated in a location to optimize emergency care. See Emergency
Medications.
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ZZtestonc,Diane D [2466374]
1/16/2018 9:01:40 AM Page 8 of 11
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Follow-Up
DAY 15 FOLLOW-UP
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, Lipase, Amylase, LDH; CHEMOTHERAPY ROOM
APPOINTMENT: nivolumab for 60 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose,
BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Lipase, Amylase, LDH;
LABS (prior to every EVEN Cycle only): TSH and Free T4; CHEMOTHERAPY ROOM APPOINTMENT: nivolumab for 60
minutes.
Day 15, Cycle 2 –  Planned for 2/27/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Advanced/Metastatic); THERAPY: nivolumab 3 mg/kg IV Day 1 and 15 (maximum dose = 240 mg);
CYCLE LENGTH: 28 days; COURSE: until disease progression.
Treatment Plan Summary (2)
DISEASE: Melanoma (Adjuvant for resected high risk patients); THERAPY: nivolumab 3 mg/kg IV Day 1 and 15
(maximum dose = 240 mg); CYCLE LENGTH: 28 days; COURSE: up to 1 year.
NOTE: High risk definition per study eligibility criteria, (2009 AJCC (seventh edition)) including: stage IIIB, IIIC, or IV
melanoma and histologically confirmed melanoma with metastases to regional lymph nodes or distant metastases that
had been surgically resected (patients with prior systemic therapy for melanoma excluded). Post surgical patients
should begin nivolumab therapy approximately 12 weeks after surgery unless adjuvant XRT is required.  Post surgical
patients requiring adjuvant XRT should begin nivolumab therapy approximately 14 to 16 weeks after surgery.
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+14 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
GLUCOSE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
BUN
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
CALCIUM
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALBUMIN
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
PROTEIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
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ZZtestonc,Diane D [2466374]
1/16/2018 9:01:40 AM Page 9 of 11
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

BILIRUBIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
LIPASE
Expected: S+14 Approximate, Expires: S+365, Routine
AMYLASE
Expected: S+14 Approximate, Expires: S+365, Routine
LD, TOTAL
Expected: S+14 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Creatinine, AST, ALT, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for Creatinine greater than 1.5 X ULN or greater than 1.5 X baseline or AST
greater than 3 X ULN or ALT greater than 3 X ULN or Total Bilirubin greater than 1.5 X ULN .
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to nivolumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Patient Instructions(1)
Advise patients to contact provider right away with signs of pneumonitis (new or worse cough, chest pain or shortness
of breath) or colitis (abdominal pain; mucus or blood in stool).
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
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ZZtestonc,Diane D [2466374]
1/16/2018 9:01:40 AM Page 10 of 11
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine (PEPCID) injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
nivolumab (OPDIVO) 3 mg/kg in sodium chloride 0.9 % 100 mL bag
3 mg/kg, Intravenous, ONCE, 1 dose Starting when released, Administer over 30 Minutes
Maximum dose = 240 mg. Administer with low protein binding in line 0.2 or 0.22 micron filter over 30 minutes. Do not
shake. Do not co-administer other drugs through same infusion line. Hypersensitivity reaction to nivolumab can occur.
For first and second dose, patient should be treated in a location to optimize emergency care. See Emergency
Medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 –  3/13/2018 through 4/9/2018 (28 days), Planned
Cycle 4 –  4/10/2018 through 5/7/2018 (28 days), Planned
Cycle 5 –  5/8/2018 through 6/4/2018 (28 days), Planned
Cycle 6 –  6/5/2018 through 7/2/2018 (28 days), Planned
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ZZtestonc,Diane D [2466374]
1/16/2018 9:01:40 AM Page 11 of 11
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org