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

CSC Melanoma Ipilimumab/Nivolumab Ver 10-25-17 (HL 5016)

CSC Melanoma Ipilimumab/Nivolumab Ver 10-25-17 (HL 5016) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Melanoma


CSC MELANOMA IPILIMUMAB/NIVOLUMAB VER: 10-25-17 (HL 5016) –  Properties
Pre-Cycle –  10/25/2017 through 10/31/2017 (7 days), Planned
Day 1, Pre-Cycle –  Planned for 10/25/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Advanced): THERAPY: nivolumab 1 mg/kg IV Day 1, ipilimumab 3 mg/kg IV Day 1; CYCLE LENGTH:
21 days; COURSE: 4 cycles followed by THERAPY: nivolumab 3 mg/kg IV Days 1 and 15 (maximum dose = 240 mg);
CYCLE LENGTH: 28 days; COURSE: 2 years or until disease progression.
Note to All Staff (1)
Due to the possible effect of treatment with ipilimumab on the immunologic response to infectious disease vaccines,
patients must not have had any infectious disease vaccination (e.g., standard influenza, H1N1 influenza, pneumococcal,
meningococcal, tetanus toxoid) within 4 weeks prior to treatment.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected: S Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S Approximate, Expires: S+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
Expected: S Approximate, Expires: S+397, Routine
PHOSPHATE
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Zztestonc,Jeff J [2507481]
11/1/2017 10:29:25 AM Page 1 of 24
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

Expected: S Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S Approximate, Expires: S+365, Routine
LD, TOTAL
Expected: S Approximate, Expires: S+365, Routine
AMYLASE
Expected: S Approximate, Expires: S+365, Routine
LIPASE
Expected: S Approximate, Expires: S+365, Routine
URIC ACID
Expected: S Approximate, Expires: S+365, Routine
TSH
Expected: S Approximate, Expires: S+365, Routine
T4, FREE
Expected: S Approximate, Expires: S+365, Routine
CORTISOL
Expected: S Approximate, Expires: S+365, Routine
URINALYSIS, NO MICROSCOPY
Expected: S Approximate, Expires: S+365, Normal, Routine
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 for nausea/vomiting., 8 mg, Disp-30 tab, R-5, EVERY 8 HOURS PRN
starting S, Local Printer
prochlorperazine (COMPAZINE) 10 MG tab
Take 1 tab by mouth every 6 hours as needed for nausea/vomiting., 10 mg, Disp-30 tab, R-5, EVERY 6 HOURS PRN
starting S, Local Printer
Cycle 1 –  11/1/2017 through 11/21/2017 (21 days), Planned
Day 1, Cycle 1 –  Planned for 11/1/2017
Treatment Plan Information
Reference Information (1)
MELANOMA: Larkin J, et al. N Engl J Med 2015;373(1):23-34.
Reference Information (2)
MELANOMA: http://www.fda.gov/Drugs/InformationOnDrugs/ApprovedDrugs/ucm520871.htm. Accessed December
19, 2016.
Treatment Plan Summary
DISEASE: Melanoma (Advanced): THERAPY: nivolumab 1 mg/kg IV Day 1, ipilimumab 3 mg/kg IV Day 1; CYCLE LENGTH:
21 days; COURSE: 4 cycles followed by THERAPY: nivolumab 3 mg/kg IV Days 1 and 15 (maximum dose = 240 mg);
CYCLE LENGTH: 28 days; COURSE: 2 years or until disease progression.
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Zztestonc,Jeff J [2507481]
11/1/2017 10:29:25 AM Page 2 of 24
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Note to All Staff (1)
Due to the possible effect of treatment with ipilimumab on the immunologic response to infectious
disease vaccines, patients must not have had any infectious disease vaccination (e.g., standard
influenza, H1N1 influenza, pneumococcal, meningococcal, tetanus toxoid) within 4 weeks prior to
treatment.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Alkaline Phosphatase, AST, ALT, Albumin, Amylase, Total
Bilirubin, Creatinine, Lipase.
Verify Labs (2)
Verify pretreatment labs have been obtained (ODD Cycles ONLY): Cortisol.
Treatment Parameters
Hold treatment and notify authorizing prescriber for WBC less than 2000/µL or Hemoglobin less than 9 g/dL or Platelets
less than 100K/µL or ANC less than 1000/µL or Alkaline Phosphatase greater than 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 or Albumin less than 2 g/dL or Creatinine greater
than 3 X ULN or Lipase greater than 2 X ULN or Amylase greater than 2 X ULN.
Treatment Parameters (2)
Hold treatment and notify authorizing prescriber for (ODD Cycles ONLY): Cortisol less than or equal to 3.0 mcg/dL.
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.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to ipilimumab can occur.  For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Monitoring Parameters (1)
Administering RN verify completion of ipilimumab REMS Nursing Checklist prior to ipilimumab administration.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Blood Pressure, Heart Rate and Respiratory Rate should be assessed every 15 minutes during infusion of nivolumab and
ipilimumab. Assess Blood Pressure, Heart Rate, Respiratory Rate and Temperature 30 minutes post-treatment.
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).
Patient Instructions(2)
Please provide patient with Ipilimumab Medication Guide each time patient receives ipilimumab. Go to reference links
in navigator.
Flush Venous Access Device per Guidelines
Order details
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Zztestonc,Jeff J [2507481]
11/1/2017 10:29:25 AM Page 3 of 24
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@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
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 in sodium chloride 0.9% (PEPCID) 2 MG/ML 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) 80 mg in sodium chloride 0.9 % 100 mL bag
80 mg (1 mg/kg × 80 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released,
Administer over 30 Minutes
Administer with low protein binding in line 0.2 or 0.22 micron filter over 30 minutes. Do not shake. Do not co-infuse
with other medications. 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.
ipilimumab (YERVOY) 240 mg in sodium chloride 0.9 % 120 mL bag
240 mg (3 mg/kg × 80 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse through a low protein binding 0.2 or 0.22 micron in-line filter over 30 minutes. Do not shake. Do not co-infuse
with other medications. Please provide patient with Medication Guide upon each administration. Hypersensitivity
reaction to ipiliumumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose,
BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, LDH, Phosphate,
Magnesium, Uric acid, Lipase, Amylase; LABS (prior to every ODD cycle only): TSH, Free T4, Cortisol; CHEMOTHERAPY
ROOM APPOINTMENT: nivolumab and ipilumumab for 90 minutes
Cycle 2 –  11/22/2017 through 12/12/2017 (21 days), Planned
Day 1, Cycle 2 –  Planned for 11/22/2017
Treatment Plan Information
Treatment Plan Summary
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Zztestonc,Jeff J [2507481]
11/1/2017 10:29:25 AM Page 4 of 24
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

DISEASE: Melanoma (Advanced): THERAPY: nivolumab 1 mg/kg IV Day 1, ipilimumab 3 mg/kg IV Day 1; CYCLE LENGTH:
21 days; COURSE: 4 cycles followed by THERAPY: nivolumab 3 mg/kg IV Days 1 and 15 (maximum dose = 240 mg);
CYCLE LENGTH: 28 days; COURSE: 2 years or until disease progression.
Note to All Staff (1)
Due to the possible effect of treatment with ipilimumab on the immunologic response to infectious disease vaccines,
patients must not have had any infectious disease vaccination (e.g., standard influenza, H1N1 influenza, pneumococcal,
meningococcal, tetanus toxoid) within 4 weeks prior to treatment.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected: S+21 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
GLUCOSE
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
BUN
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
CALCIUM
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
ALBUMIN
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
PROTEIN, TOTAL
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
LD, TOTAL
Expected: S+21 Approximate, Expires: S+365, Routine
PHOSPHATE
Expected: S+21 Approximate, Expires: S+365, Routine
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Zztestonc,Jeff J [2507481]
11/1/2017 10:29:25 AM Page 5 of 24
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

MAGNESIUM
Expected: S+21 Approximate, Expires: S+365, Routine
AMYLASE
Expected: S+21, Expires: S+365, Routine
LIPASE
Expected: S+21, Expires: S+365, Routine
URIC ACID
Expected: S+21, Expires: S+365, Routine
Pre-Labs (delete all that do not apply)
TSH
Expected: S+21 Approximate, Expires: S+365, Routine
Prior to every ODD Cycle only.
T4, FREE
Expected: S+21 Approximate, Expires: S+365, Routine
Prior to every ODD Cycle only.
CORTISOL
Expected: S+21 Approximate, Expires: S+365, Routine
Prior to every ODD Cycle only.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Alkaline Phosphatase, AST, ALT, Albumin, Amylase, Total
Bilirubin, Creatinine, Lipase.
Verify Labs (2)
Verify pretreatment labs have been obtained (ODD Cycles ONLY): Cortisol.
Treatment Parameters
Hold treatment and notify authorizing prescriber for WBC less than 2000/µL or Hemoglobin less than 9 g/dL or Platelets
less than 100K/µL or ANC less than 1000/µL or Alkaline Phosphatase greater than 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 or Albumin less than 2 g/dL or Creatinine greater
than 3 X ULN or Creatinine greater than 3 X Patient's Baseline or Amylase greater than 2 X ULN or Lipase greater than 2
X ULN.
Treatment Parameters (2)
Hold treatment and notify authorizing prescriber for (ODD Cycles ONLY): Cortisol less than or equal to 3.0 mcg/dL.
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.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to ipilimumab can occur.  For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Monitoring Parameters (1)
Administering RN verify completion of ipilimumab REMS Nursing Checklist prior to ipilimumab administration.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Blood Pressure, Heart Rate and Respiratory Rate should be assessed every 15 minutes during infusion of nivolumab and
ipilimumab. Assess Blood Pressure, Heart Rate, Respiratory Rate and Temperature 30 minutes post-treatment.
Patient Instructions(1)
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Zztestonc,Jeff J [2507481]
11/1/2017 10:29:25 AM Page 6 of 24
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

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).
Patient Instructions(2)
Please provide patient with Ipilimumab Medication Guide each time patient receives ipilimumab. Go to reference links
in navigator.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
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 in sodium chloride 0.9% (PEPCID) 2 MG/ML 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) 80 mg in sodium chloride 0.9 % 100 mL bag
80 mg (1 mg/kg × 80 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released,
Administer over 30 Minutes
Administer with low protein binding in line 0.2 or 0.22 micron filter over 30 minutes. Do not shake. Do not co-infuse
with other medications. 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.
ipilimumab (YERVOY) 240 mg in sodium chloride 0.9 % 120 mL bag
240 mg (3 mg/kg × 80 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse through a low protein binding 0.2 or 0.22 micron in-line filter over 30 minutes. Do not shake. Do not co-infuse
with other medications. Please provide patient with Medication Guide upon each administration. Hypersensitivity
reaction to ipiliumumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose,
BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, LDH, Phosphate,
Magnesium, Uric acid, Lipase, Amylase; LABS (prior to every ODD cycle only): TSH, Free T4, Cortisol; CHEMOTHERAPY
ROOM APPOINTMENT: nivolumab and ipilumumab for 90 minutes
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Zztestonc,Jeff J [2507481]
11/1/2017 10:29:25 AM Page 7 of 24
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Cycle 3 –  12/13/2017 through 1/2/2018 (21 days), Planned
Day 1, Cycle 3 –  Planned for 12/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Advanced): THERAPY: nivolumab 1 mg/kg IV Day 1, ipilimumab 3 mg/kg IV Day 1; CYCLE LENGTH:
21 days; COURSE: 4 cycles followed by THERAPY: nivolumab 3 mg/kg IV Days 1 and 15 (maximum dose = 240 mg);
CYCLE LENGTH: 28 days; COURSE: 2 years or until disease progression.
Note to All Staff (1)
Due to the possible effect of treatment with ipilimumab on the immunologic response to infectious disease vaccines,
patients must not have had any infectious disease vaccination (e.g., standard influenza, H1N1 influenza, pneumococcal,
meningococcal, tetanus toxoid) within 4 weeks prior to treatment.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected: S+21 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
GLUCOSE
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
BUN
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
CALCIUM
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
ALBUMIN
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
PROTEIN, TOTAL
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
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Zztestonc,Jeff J [2507481]
11/1/2017 10:29:25 AM Page 8 of 24
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

ALKALINE PHOSPHATASE
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
LD, TOTAL
Expected: S+21 Approximate, Expires: S+365, Routine
PHOSPHATE
Expected: S+21 Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S+21 Approximate, Expires: S+365, Routine
AMYLASE
Expected: S+21, Expires: S+365, Routine
LIPASE
Expected: S+21, Expires: S+365, Routine
URIC ACID
Expected: S+21, Expires: S+365, Routine
Pre-Labs (delete all that do not apply)
TSH
Expected: S+21 Approximate, Expires: S+365, Routine
Prior to every ODD Cycle only.
T4, FREE
Expected: S+21 Approximate, Expires: S+365, Routine
Prior to every ODD Cycle only.
CORTISOL
Expected: S+21 Approximate, Expires: S+365, Routine
Prior to every ODD Cycle only.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Alkaline Phosphatase, AST, ALT, Albumin, Amylase, Total
Bilirubin, Creatinine, Lipase.
Verify Labs (2)
Verify pretreatment labs have been obtained (ODD Cycles ONLY): Cortisol.
Treatment Parameters
Hold treatment and notify authorizing prescriber for WBC less than 2000/µL or Hemoglobin less than 9 g/dL or Platelets
less than 100K/µL or ANC less than 1000/µL or Alkaline Phosphatase greater than 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 or Albumin less than 2 g/dL or Creatinine greater
than 3 X ULN or Creatinine greater than 3 X Patient's Baseline or Amylase greater than 2 X ULN or Lipase greater than 2
X ULN.
Treatment Parameters (2)
Hold treatment and notify authorizing prescriber for (ODD Cycles ONLY): Cortisol less than or equal to 3.0 mcg/dL.
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.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to ipilimumab can occur.  For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
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Zztestonc,Jeff J [2507481]
11/1/2017 10:29:25 AM Page 9 of 24
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Monitoring Parameters (1)
Administering RN verify completion of ipilimumab REMS Nursing Checklist prior to ipilimumab
administration.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Blood Pressure, Heart Rate and Respiratory Rate should be assessed every 15 minutes during infusion of nivolumab and
ipilimumab. Assess Blood Pressure, Heart Rate, Respiratory Rate and Temperature 30 minutes post-treatment.
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).
Patient Instructions(2)
Please provide patient with Ipilimumab Medication Guide each time patient receives ipilimumab. Go to reference links
in navigator.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
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 in sodium chloride 0.9% (PEPCID) 2 MG/ML 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) 80 mg in sodium chloride 0.9 % 100 mL bag
80 mg (1 mg/kg × 80 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released,
Administer over 30 Minutes
Administer with low protein binding in line 0.2 or 0.22 micron filter over 30 minutes. Do not shake. Do not co-infuse
with other medications. 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.
ipilimumab (YERVOY) 240 mg in sodium chloride 0.9 % 120 mL bag
240 mg (3 mg/kg × 80 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse through a low protein binding 0.2 or 0.22 micron in-line filter over 30 minutes. Do not shake. Do not co-infuse
with other medications. Please provide patient with Medication Guide upon each administration. Hypersensitivity
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Zztestonc,Jeff J [2507481]
11/1/2017 10:29:25 AM Page 10 of 24
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

reaction to ipiliumumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose,
BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, LDH, Phosphate,
Magnesium, Uric acid, Lipase, Amylase; LABS (prior to every ODD cycle only): TSH, Free T4, Cortisol; CHEMOTHERAPY
ROOM APPOINTMENT: nivolumab and ipilumumab for 90 minutes
Cycle 4 –  1/3/2018 through 1/23/2018 (21 days), Planned
Day 1, Cycle 4 –  Planned for 1/3/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Advanced): THERAPY: nivolumab 1 mg/kg IV Day 1, ipilimumab 3 mg/kg IV Day 1; CYCLE LENGTH:
21 days; COURSE: 4 cycles followed by THERAPY: nivolumab 3 mg/kg IV Days 1 and 15 (maximum dose = 240 mg);
CYCLE LENGTH: 28 days; COURSE: 2 years or until disease progression.
Note to All Staff (1)
Due to the possible effect of treatment with ipilimumab on the immunologic response to infectious disease vaccines,
patients must not have had any infectious disease vaccination (e.g., standard influenza, H1N1 influenza, pneumococcal,
meningococcal, tetanus toxoid) within 4 weeks prior to treatment.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected: S+21 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
GLUCOSE
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
BUN
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
CALCIUM
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
ALBUMIN
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
PROTEIN, TOTAL
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Zztestonc,Jeff J [2507481]
11/1/2017 10:29:25 AM Page 11 of 24
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Expected: S+21 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
PHOSPHATE
Expected: S+21 Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S+21 Approximate, Expires: S+365, Routine
LD, TOTAL
Expected: S+21 Approximate, Expires: S+365, Routine
AMYLASE
Expected: S+21, Expires: S+365, Routine
LIPASE
Expected: S+21, Expires: S+365, Routine
URIC ACID
Expected: S+21, Expires: S+365, Routine
Pre-Labs (delete all that do not apply)
TSH
Expected: S+21 Approximate, Expires: S+365, Routine
Prior to every ODD Cycle only.
T4, FREE
Expected: S+21 Approximate, Expires: S+365, Routine
Prior to every ODD Cycle only.
CORTISOL
Expected: S+21 Approximate, Expires: S+365, Routine
Prior to every ODD Cycle only.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Alkaline Phosphatase, AST, ALT, Albumin, Amylase, Total
Bilirubin, Creatinine, Lipase.
Verify Labs (2)
Verify pretreatment labs have been obtained (ODD Cycles ONLY): Cortisol.
Treatment Parameters
Hold treatment and notify authorizing prescriber for WBC less than 2000/µL or Hemoglobin less than 9 g/dL or Platelets
less than 100K/µL or ANC less than 1000/µL or Alkaline Phosphatase greater than 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 or Albumin less than 2 g/dL or Creatinine greater
than 3 X ULN or Creatinine greater than 3 X Patient's Baseline or Amylase greater than 2 X ULN or Lipase greater than 2
X ULN.
Treatment Parameters (2)
Hold treatment and notify authorizing prescriber for (ODD Cycles ONLY): Cortisol less than or equal to 3.0 mcg/dL.
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Zztestonc,Jeff J [2507481]
11/1/2017 10:29:25 AM Page 12 of 24
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

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.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to ipilimumab can occur.  For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Monitoring Parameters (1)
Administering RN verify completion of ipilimumab REMS Nursing Checklist prior to ipilimumab administration.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Blood Pressure, Heart Rate and Respiratory Rate should be assessed every 15 minutes during infusion of nivolumab and
ipilimumab. Assess Blood Pressure, Heart Rate, Respiratory Rate and Temperature 30 minutes post-treatment.
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).
Patient Instructions(2)
Please provide patient with Ipilimumab Medication Guide each time patient receives ipilimumab. Go to reference links
in navigator.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
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 in sodium chloride 0.9% (PEPCID) 2 MG/ML 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) 80 mg in sodium chloride 0.9 % 100 mL bag
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Zztestonc,Jeff J [2507481]
11/1/2017 10:29:25 AM Page 13 of 24
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

80 mg (1 mg/kg × 80 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released,
Administer over 30 Minutes
Administer with low protein binding in line 0.2 or 0.22 micron filter over 30 minutes. Do not shake. Do not co-infuse
with other medications. 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.
ipilimumab (YERVOY) 240 mg in sodium chloride 0.9 % 120 mL bag
240 mg (3 mg/kg × 80 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse through a low protein binding 0.2 or 0.22 micron in-line filter over 30 minutes. Do not shake. Do not co-infuse
with other medications. Please provide patient with Medication Guide upon each administration. Hypersensitivity
reaction to ipiliumumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose,
BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, LDH, Phosphate,
Magnesium, Uric acid, Lipase, Amylase; LABS (prior to every ODD cycle only): TSH, Free T4, Cortisol; CHEMOTHERAPY
ROOM APPOINTMENT: nivolumab for 60 minutes.
Cycle 5 –  1/24/2018 through 2/20/2018 (28 days), Planned
Day 1, Cycle 5 –  Planned for 1/24/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Advanced): THERAPY: nivolumab 1 mg/kg IV Day 1, ipilimumab 3 mg/kg IV Day 1; CYCLE LENGTH:
21 days; COURSE: 4 cycles followed by THERAPY: nivolumab 3 mg/kg IV Days 1 and 15 (maximum dose = 240 mg);
CYCLE LENGTH: 28 days; COURSE: 2 years or until disease progression.
Note to All Staff (1)
Due to the possible effect of treatment with ipilimumab on the immunologic response to infectious disease vaccines,
patients must not have had any infectious disease vaccination (e.g., standard influenza, H1N1 influenza, pneumococcal,
meningococcal, tetanus toxoid) within 4 weeks prior to treatment.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected: S+21 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
GLUCOSE
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
BUN
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
CREATININE
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Zztestonc,Jeff J [2507481]
11/1/2017 10:29:25 AM Page 14 of 24
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Expected: S+21 Approximate, Expires: S+365, Normal, Routine
CALCIUM
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
ALBUMIN
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
PROTEIN, TOTAL
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+21 Approximate, Expires: S+365, Normal, Routine
PHOSPHATE
Expected: S+21 Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S+21 Approximate, Expires: S+365, Routine
LD, TOTAL
Expected: S+21 Approximate, Expires: S+365, Routine
AMYLASE
Expected: S+21, Expires: S+365, Routine
LIPASE
Expected: S+21, Expires: S+365, Routine
URIC ACID
Expected: S+21, Expires: S+365, Routine
Pre-Labs (delete all that do not apply)
TSH
Expected: S+21 Approximate, Expires: S+365, Routine
Prior to every ODD Cycle only.
T4, FREE
Expected: S+21 Approximate, Expires: S+365, Routine
Prior to every ODD Cycle only.
CORTISOL
Expected: S+21 Approximate, Expires: S+365, Routine
Prior to every ODD Cycle only.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Alkaline Phosphatase, AST, ALT, Albumin, Amylase, Total
Bilirubin, Creatinine, Lipase.
Verify Labs (2)
Verify pretreatment labs have been obtained (ODD Cycles ONLY): Cortisol.
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Zztestonc,Jeff J [2507481]
11/1/2017 10:29:25 AM Page 15 of 24
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Treatment Parameters
Hold treatment and notify authorizing prescriber for WBC less than 2000/µL or Hemoglobin less than 9
g/dL or Platelets less than 100K/µL or ANC less than 1000/µL or Alkaline Phosphatase greater than 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
or Albumin less than 2 g/dL or Creatinine greater than 3 X ULN or Creatinine greater than 3 X Patient's
Baseline or Amylase greater than 2 X ULN or Lipase greater than 2 X ULN.
Treatment Parameters (2)
Hold treatment and notify authorizing prescriber for (ODD Cycles ONLY): Cortisol less than or equal to 3.0 mcg/dL.
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 in sodium chloride 0.9% (PEPCID) 2 MG/ML 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) 220 mg in sodium chloride 0.9 % 100 mL bag
220 mg (rounded from 240 mg = 3 mg/kg × 80 kg Treatment plan recorded weight), 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,Jeff J [2507481]
11/1/2017 10:29:25 AM Page 16 of 24
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@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, LDH, Phosphate, Magnesium, Uric acid, Lipase,
Amylase; 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, LDH, Phosphate,
Magnesium, Uric acid, Lipase, Amylase; LABS (prior to every ODD cycle only): TSH, Free T4, Cortisol; CHEMOTHERAPY
ROOM APPOINTMENT: nivolumab for 60 minutes.
Day 15, Cycle 5 –  Planned for 2/7/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Advanced): THERAPY: nivolumab 1 mg/kg IV Day 1, ipilimumab 3 mg/kg IV Day 1; CYCLE LENGTH:
21 days; COURSE: 4 cycles followed by THERAPY: nivolumab 3 mg/kg IV Days 1 and 15 (maximum dose = 240 mg);
CYCLE LENGTH: 28 days; COURSE: 2 years or until disease progression.
Note to All Staff (1)
Due to the possible effect of treatment with ipilimumab on the immunologic response to infectious disease vaccines,
patients must not have had any infectious disease vaccination (e.g., standard influenza, H1N1 influenza, pneumococcal,
meningococcal, tetanus toxoid) within 4 weeks prior to treatment.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
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
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Zztestonc,Jeff J [2507481]
11/1/2017 10:29:25 AM Page 17 of 24
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

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
PHOSPHATE
Expected: S+14 Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S+14 Approximate, Expires: S+365, Routine
LD, TOTAL
Expected: S+14 Approximate, Expires: S+365, Routine
AMYLASE
Expected: S+14 Approximate, Expires: S+365, Routine
LIPASE
Expected: S+14 Approximate, Expires: S+365, Routine
URIC ACID
Expected: S+14 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Alkaline Phosphatase, AST, ALT, Albumin, Amylase, Total
Bilirubin, Creatinine, Lipase.
Treatment Parameters
Hold treatment and notify authorizing prescriber for WBC less than 2000/µL or Hemoglobin less than 9 g/dL or Platelets
less than 100K/µL or ANC less than 1000/µL or Alkaline Phosphatase greater than 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 or Albumin less than 2 g/dL or Creatinine greater
than 3 X ULN or Creatinine greater than 3 X Patient's Baseline or Amylase greater than 2 X ULN or Lipase greater than 2
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.
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Zztestonc,Jeff J [2507481]
11/1/2017 10:29:25 AM Page 18 of 24
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

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 in sodium chloride 0.9% (PEPCID) 2 MG/ML 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) 220 mg in sodium chloride 0.9 % 100 mL bag
220 mg (rounded from 240 mg = 3 mg/kg × 80 kg Treatment plan recorded weight), 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 6 –  2/21/2018 through 3/20/2018 (28 days), Planned
Day 1, Cycle 6 –  Planned for 2/21/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Advanced): THERAPY: nivolumab 1 mg/kg IV Day 1, ipilimumab 3 mg/kg IV Day 1; CYCLE LENGTH:
21 days; COURSE: 4 cycles followed by THERAPY: nivolumab 3 mg/kg IV Days 1 and 15 (maximum dose = 240 mg);
CYCLE LENGTH: 28 days; COURSE: 2 years or until disease progression.
Note to All Staff (1)
Due to the possible effect of treatment with ipilimumab on the immunologic response to infectious disease vaccines,
patients must not have had any infectious disease vaccination (e.g., standard influenza, H1N1 influenza, pneumococcal,
meningococcal, tetanus toxoid) within 4 weeks prior to treatment.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
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Zztestonc,Jeff J [2507481]
11/1/2017 10:29:25 AM Page 19 of 24
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

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
PHOSPHATE
Expected: S+14 Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S+14 Approximate, Expires: S+365, Routine
LD, TOTAL
Expected: S+14 Approximate, Expires: S+365, Routine
AMYLASE
Expected: S+14 Approximate, Expires: S+365, Routine
LIPASE
Expected: S+14 Approximate, Expires: S+365, Routine
URIC ACID
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
Prior to every ODD Cycle only.
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Zztestonc,Jeff J [2507481]
11/1/2017 10:29:25 AM Page 20 of 24
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

T4, FREE
Expected: S+14 Approximate, Expires: S+365, Routine
Prior to every ODD Cycle only.
CORTISOL
Expected: S+14 Approximate, Expires: S+365, Routine
Prior to every ODD Cycle only.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Alkaline Phosphatase, AST, ALT, Albumin, Amylase, Total
Bilirubin, Creatinine, Lipase.
Verify Labs (2)
Verify pretreatment labs have been obtained (ODD Cycles ONLY): Cortisol.
Treatment Parameters
Hold treatment and notify authorizing prescriber for WBC less than 2000/µL or Hemoglobin less than 9 g/dL or Platelets
less than 100K/µL or ANC less than 1000/µL or Alkaline Phosphatase greater than 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 or Albumin less than 2 g/dL or Creatinine greater
than 3 X ULN or Creatinine greater than 3 X Patient's Baseline or Amylase greater than 2 X ULN or Lipase greater than 2
X ULN.
Treatment Parameters (2)
Hold treatment and notify authorizing prescriber for (ODD Cycles ONLY): Cortisol less than or equal to 3.0 mcg/dL.
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
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Zztestonc,Jeff J [2507481]
11/1/2017 10:29:25 AM Page 21 of 24
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML 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) 220 mg in sodium chloride 0.9 % 100 mL bag
220 mg (rounded from 240 mg = 3 mg/kg × 80 kg Treatment plan recorded weight), 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, LDH, Phosphate, Magnesium, Uric acid, Lipase,
Amylase; 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, LDH, Phosphate,
Magnesium, Uric acid, Lipase, Amylase; LABS (prior to every ODD cycle only): TSH, Free T4, Cortisol; CHEMOTHERAPY
ROOM APPOINTMENT: nivolumab for 60 minutes.
Day 15, Cycle 6 –  Planned for 3/7/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Advanced): THERAPY: nivolumab 1 mg/kg IV Day 1, ipilimumab 3 mg/kg IV Day 1; CYCLE LENGTH:
21 days; COURSE: 4 cycles followed by THERAPY: nivolumab 3 mg/kg IV Days 1 and 15 (maximum dose = 240 mg);
CYCLE LENGTH: 28 days; COURSE: 2 years or until disease progression.
Note to All Staff (1)
Due to the possible effect of treatment with ipilimumab on the immunologic response to infectious disease vaccines,
patients must not have had any infectious disease vaccination (e.g., standard influenza, H1N1 influenza, pneumococcal,
meningococcal, tetanus toxoid) within 4 weeks prior to treatment.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
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
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Zztestonc,Jeff J [2507481]
11/1/2017 10:29:25 AM Page 22 of 24
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

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
PHOSPHATE
Expected: S+14 Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S+14 Approximate, Expires: S+365, Routine
LD, TOTAL
Expected: S+14 Approximate, Expires: S+365, Routine
AMYLASE
Expected: S+14 Approximate, Expires: S+365, Routine
LIPASE
Expected: S+14 Approximate, Expires: S+365, Routine
URIC ACID
Expected: S+14 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Alkaline Phosphatase, AST, ALT, Albumin, Amylase, Total
Bilirubin, Creatinine, Lipase.
Treatment Parameters
Hold treatment and notify authorizing prescriber for WBC less than 2000/µL or Hemoglobin less than 9 g/dL or Platelets
less than 100K/µL or ANC less than 1000/µL or Alkaline Phosphatase greater than 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 or Albumin less than 2 g/dL or Creatinine greater
than 3 X ULN or Creatinine greater than 3 X Patient's Baseline or Amylase greater than 2 X ULN or Lipase greater than 2
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)
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Zztestonc,Jeff J [2507481]
11/1/2017 10:29:25 AM Page 23 of 24
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

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 in sodium chloride 0.9% (PEPCID) 2 MG/ML 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) 220 mg in sodium chloride 0.9 % 100 mL bag
220 mg (rounded from 240 mg = 3 mg/kg × 80 kg Treatment plan recorded weight), 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.
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Zztestonc,Jeff J [2507481]
11/1/2017 10:29:25 AM Page 24 of 24
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org