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RESEARCH PRO00016419 / BERNICKER EA5142 (ADJUVANT NIVOLUMAB)	

Types:      Research Oncology Treatment
Synonyms:  INV-NIVOLUMAB, EA5142

Screening	Repeat 1 time	Cycle length: 14 days	LESS THAN or EQUAL 2 weeks before randomization	Perform every 1 day x1		Nursing Orders
  	VITAL SIGNS - T/P/R/BP	Interval: --	Occurrences: --	Comments:	Blood pressure, body temperature, heart rate
		  	PULSE OXIMETRY	Interval: --	Occurrences: --		  	RESEARCH - HEIGHT AND WEIGHT	Interval: --	Occurrences: --		  	ONC NURSING COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	ECOG performance status
			Nursing Orders
  	ECG 12-LEAD	Interval: --	Occurrences: --	Comments:	Only for patient with History of CHF or underlying cardiovascular diseases or exposure to Cardio toxic drug
			Procedures
  	CV ECHOCARDIOGRAM RESEARCH ONLY	Interval: --	Occurrences: --	Comments:	Only for patient with History of CHF or underlying cardiovascular diseases or exposure to Cardio toxic drug
			Imaging
  	CT CHEST W WO CONTRAST	Interval: --	Occurrences: --	Comments:	Including adrenals (within 1 month of randomization and every 6 months)
			Labs
  	HCG QUALITATIVE, SERUM SCREEN	Interval: --	Occurrences: --	Comments:	Only for women of childbearing potential
		  	HCG QUANTITATIVE, SERUM	Interval: --	Occurrences: --	Comments:	Only for women of childbearing potential
		  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		  	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		  	THYROID STIMULATING HORMONE	Interval: --	Occurrences: --		  	T3, FREE	Interval: --	Occurrences: --	Comments:	Only If TSH is abnormal
		  	T4, FREE	Interval: --	Occurrences: --	Comments:	Only If TSH is abnormal
		  	RESEARCH STUDY SPECIMEN	Interval: --	Occurrences: --		  	HIV 1/2 ANTIGEN/ANTIBODY, FOURTH GENERATION, WITH REFLEXES	Interval: --	Occurrences: --		  	HEPATITIS B CORE ANTIBODY IGM	Interval: --	Occurrences: --		  	HEPATITIS C ANTIBODY	Interval: --	Occurrences: --					
Cycle 1	Repeat 1 time	Cycle length: 28 days	Day 1 (Within 14 working days of Randomization)	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Line Care
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Nursing Orders
  	ONC NURSING COMMUNICATION 9	Interval: --	Occurrences: --	Comments:	Physical Exam (can be performed 48 hours prior to treatment).
		  	VITAL SIGNS - T/P/R/BP	Interval: --	Occurrences: --	Comments:	Pre-dose:  Blood pressure, body temperature, heart rate
		  	RESEARCH - MEASURE WEIGHT	Interval: --	Occurrences: --	Comments:	Pre-dose
		  	ONC NURSING COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	ECOG performance status
			Labs
  	HCG QUALITATIVE, SERUM SCREEN	Interval: --	Occurrences: --	Comments:	Only for women of childbearing potential
		  	HCG QUANTITATIVE, SERUM	Interval: --	Occurrences: --	Comments:	Only for women of childbearing potential
		  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		  	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		  	THYROID STIMULATING HORMONE	Interval: --	Occurrences: --		  	T3, FREE	Interval: --	Occurrences: --	Comments:	Only If TSH is abnormal
		  	T4, FREE	Interval: --	Occurrences: --	Comments:	Only If TSH is abnormal
			Chemotherapy
  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	Nivolumab is administered at a flat dose. The dose is 480 mg (administered every 4 weeks +/- 2 days) for up to 1 year total. Nivolumab is to be administered as a 30-minute (+/-5 minutes) IV infusion. The drug can be infused undiluted or diluted with 0.9% normal saline or 5% dextrose for delivery but the total drug concentration of the solution should be between 2mg/mL - 10mg/mL. It is not to be administered as an IV push or bolus injection. At the end of the infusion, flush the line with a sufficient quantity of normal saline. The total infusion volume should not exceed 120 mL.
		  	ONC NURSING COMMUNICATION 6	Interval: --	Occurrences: --	Comments:	Premedications are not given prior to the first dose of Nivolumab.
			Chemotherapy
  	INV-Nivolumab (EA5142/Pro00016419/Bernicker) 10 mg/mL 480 mg in sodium chloride 0.9% 100 mL (4.8 mg/mL) infusion	Dose: 480 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S	End: S		Instructions:	Prepared dose contains open label active Nivolumab. Administer intravenously via pump, using 0.2 to 1.2 micron inline filter, over 30 minutes. Stability of prepared dose: Room temperature, including infusion time: 4 hours. Refrigerated: 20 hours.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-NIVOLUMAB VIAL (EA5142/PRO00016419/BERNICKER)	Medications	480 mg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	52 mL	Yes	Yes				Discharge Nursing Orders
  	ONC NURSING COMMUNICATION 76	Interval: --	Occurrences: --	Comments:	Discontinue IV.
			Discharge Nursing Orders
☑	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN					☑	HEParin, porcine (PF) injection 500 Units	Dose: 500 Units	Route: intra-catheter	once PRN	Start: S			Instructions:	Concentration: 100 units/mL. Heparin flush for Implanted Vascular Access Device maintenance.					
Cycle 2	Repeat 1 time	Cycle length: 28 days	Day 1 (Infusion day)	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Line Care
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Nursing Orders
  	VITAL SIGNS - T/P/R/BP	Interval: --	Occurrences: --	Comments:	Pre-dose:  Blood pressure, body temperature, heart rate
		  	RESEARCH - MEASURE WEIGHT	Interval: --	Occurrences: --	Comments:	Pre-dose
		  	ONC NURSING COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	ECOG performance status
			Labs
  	HCG QUALITATIVE, SERUM SCREEN	Interval: --	Occurrences: --	Comments:	Only for women of childbearing potential
		  	HCG QUANTITATIVE, SERUM	Interval: --	Occurrences: --	Comments:	Only for women of childbearing potential
		  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		  	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		  	THYROID STIMULATING HORMONE	Interval: --	Occurrences: --		  	T3, FREE	Interval: --	Occurrences: --	Comments:	Only If TSH is abnormal
		  	T4, FREE	Interval: --	Occurrences: --	Comments:	Only If TSH is abnormal
			Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: --	Occurrences: --	Comments:	Grade 1 - MILD Symptoms (cutaneous and subcutaneous symptoms only - itching, flushing, periorbital edema, rash, or runny nose)
1. Stop the infusion.
2. Place the patient on continuous monitoring.
3. Obtain vital signs.
4. Administer Normal Saline at 50 mL per hour using a new bag and new intravenous tubing.
5. If greater than or equal to 30 minutes since the last dose of Diphenhydramine, administer Diphenhydramine 25 mg intravenous once.
6. If less than 30 minutes since the last dose of Diphenhydramine, administer Cetirizine 10 mg orally and Famotidine 20 mg intravenous once.
7. Notify the treating physician.
8. If no improvement after 15 minutes, advance level of care to Grade 2 (Moderate) or Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 4	Interval: --	Occurrences: --	Comments:	Grade 2 - MODERATE Symptoms (cardiovascular, respiratory, or gastrointestinal symptoms - shortness of breath, wheezing, nausea, vomiting, dizziness, diaphoresis, throat or chest tightness, abdominal or back pain)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
6. Administer Normal Saline at 150 mL per hour using a new bag and new intravenous tubing.
7. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous), Cetirizine 10 mg orally and Famotidine 20 mg intravenous once.
8. If no improvement after 15 minutes, advance level of care to Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 83	Interval: --	Occurrences: --	Comments:	Grade 3 – SEVERE Symptoms (hypoxia, hypotension, or neurologic compromise – cyanosis or O2 saturation less than 92%, hypotension with systolic blood pressure less than 90 mmHg, confusion, collapse, loss of consciousness, or incontinence)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. If heart rate is less than 50 or greater than 120, or blood pressure is less than 90/50 mmHg, place patient in reclined or flattened position.
6. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
7. Administer Normal Saline at 1000 mL intravenous bolus using a new bag and new intravenous tubing.
8. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous) and Famotidine 20 mg intravenous once.
9. Administer Epinephrine (1:1000) 0.3 mg subcutaneous.
10. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	PRN	Start: S				  	cetirizine (ZyrTEC) tablet 10 mg	Dose: 10 mg	Route: oral	once PRN	Start: S				  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	PRN	Start: S				  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	PRN					  	dexAMETHasone (DECADRON) IV 4 mg	Dose: 4 mg	Route: intravenous	PRN					  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					Pre-Medications
  	diphenhydrAMINE (BENADRYL) injection 50 mg	Dose: 50 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer if a grade 1 or 2 infusion related reaction occurs.		  	acetaminophen (TYLENOL) tablet 325 mg	Dose: 325 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer if a grade 1 or 2 infusion related reaction occurs.		  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer if a grade 1 or 2 infusion related reaction occurs.		  	acetaminophen (TYLENOL) tablet 975 mg	Dose: 975 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer if a grade 1 or 2 infusion related reaction occurs.			Chemotherapy
  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	Nivolumab is administered at a flat dose. The dose is 480 mg (administered every 4 weeks +/- 2 days) for up to 1 year total. Nivolumab is to be administered as a 30-minute (+/-5 minutes) IV infusion. The drug can be infused undiluted or diluted with 0.9% normal saline or 5% dextrose for delivery but the total drug concentration of the solution should be between 2mg/mL - 10mg/mL. It is not to be administered as an IV push or bolus injection. At the end of the infusion, flush the line with a sufficient quantity of normal saline. The total infusion volume should not exceed 120 mL.
		  	ONC NURSING COMMUNICATION 8	Interval: --	Occurrences: --	Comments:	If a grade 1 or 2 infusion related reaction occurs, patients may be administered premedication prior to future Nivolumab infusions with diphenhydramine 50 mg and acetaminophen 325 to 1000 mg administered. The Nivolumab should start at least 30 minutes after the start of second premedication.
		  	ONC NURSING COMMUNICATION 9	Interval: --	Occurrences: --	Comments:	All the subsequent cycles for 1 year since first dose of Nivolumab will be similar as Cycle 2.
			Chemotherapy
  	INV-Nivolumab (EA5142/Pro00016419/Bernicker) 10 mg/mL 480 mg in sodium chloride 0.9% 100 mL (4.8 mg/mL) infusion	Dose: 480 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S	End: S		Instructions:	Prepared dose contains open label active Nivolumab. Administer intravenously via pump, using 0.2 to 1.2 micron inline filter, over 30 minutes. Stability of prepared dose: Room temperature, including infusion time: 4 hours. Refrigerated: 20 hours.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-NIVOLUMAB VIAL (EA5142/PRO00016419/BERNICKER)	Medications	480 mg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	52 mL	Yes	Yes				Discharge Nursing Orders
  	ONC NURSING COMMUNICATION 76	Interval: --	Occurrences: --	Comments:	Discontinue IV.
			Discharge Nursing Orders
☑	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN					☑	HEParin, porcine (PF) injection 500 Units	Dose: 500 Units	Route: intra-catheter	once PRN	Start: S			Instructions:	Concentration: 100 units/mL. Heparin flush for Implanted Vascular Access Device maintenance.					
Cycle 3	Repeat 1 time	Cycle length: 28 days	Day 1 (Infusion day)	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Line Care
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Nursing Orders
  	VITAL SIGNS - T/P/R/BP	Interval: --	Occurrences: --	Comments:	Pre-dose:  Blood pressure, body temperature, heart rate
		  	RESEARCH - MEASURE WEIGHT	Interval: --	Occurrences: --	Comments:	Pre-dose
		  	ONC NURSING COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	ECOG performance status
			Labs
  	HCG QUALITATIVE, SERUM SCREEN	Interval: --	Occurrences: --	Comments:	Only for women of childbearing potential
		  	HCG QUANTITATIVE, SERUM	Interval: --	Occurrences: --	Comments:	Only for women of childbearing potential
		  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		  	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		  	THYROID STIMULATING HORMONE	Interval: --	Occurrences: --		  	T3, FREE	Interval: --	Occurrences: --	Comments:	Only If TSH is abnormal
		  	T4, FREE	Interval: --	Occurrences: --	Comments:	Only If TSH is abnormal
			Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: --	Occurrences: --	Comments:	Grade 1 - MILD Symptoms (cutaneous and subcutaneous symptoms only - itching, flushing, periorbital edema, rash, or runny nose)
1. Stop the infusion.
2. Place the patient on continuous monitoring.
3. Obtain vital signs.
4. Administer Normal Saline at 50 mL per hour using a new bag and new intravenous tubing.
5. If greater than or equal to 30 minutes since the last dose of Diphenhydramine, administer Diphenhydramine 25 mg intravenous once.
6. If less than 30 minutes since the last dose of Diphenhydramine, administer Cetirizine 10 mg orally and Famotidine 20 mg intravenous once.
7. Notify the treating physician.
8. If no improvement after 15 minutes, advance level of care to Grade 2 (Moderate) or Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 4	Interval: --	Occurrences: --	Comments:	Grade 2 - MODERATE Symptoms (cardiovascular, respiratory, or gastrointestinal symptoms - shortness of breath, wheezing, nausea, vomiting, dizziness, diaphoresis, throat or chest tightness, abdominal or back pain)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
6. Administer Normal Saline at 150 mL per hour using a new bag and new intravenous tubing.
7. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous), Cetirizine 10 mg orally and Famotidine 20 mg intravenous once.
8. If no improvement after 15 minutes, advance level of care to Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 83	Interval: --	Occurrences: --	Comments:	Grade 3 – SEVERE Symptoms (hypoxia, hypotension, or neurologic compromise – cyanosis or O2 saturation less than 92%, hypotension with systolic blood pressure less than 90 mmHg, confusion, collapse, loss of consciousness, or incontinence)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. If heart rate is less than 50 or greater than 120, or blood pressure is less than 90/50 mmHg, place patient in reclined or flattened position.
6. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
7. Administer Normal Saline at 1000 mL intravenous bolus using a new bag and new intravenous tubing.
8. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous) and Famotidine 20 mg intravenous once.
9. Administer Epinephrine (1:1000) 0.3 mg subcutaneous.
10. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	PRN	Start: S				  	cetirizine (ZyrTEC) tablet 10 mg	Dose: 10 mg	Route: oral	once PRN	Start: S				  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	PRN	Start: S				  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	PRN					  	dexAMETHasone (DECADRON) IV 4 mg	Dose: 4 mg	Route: intravenous	PRN					  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					Pre-Medications
  	diphenhydrAMINE (BENADRYL) injection 50 mg	Dose: 50 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer if a grade 1 or 2 infusion related reaction occurs.		  	acetaminophen (TYLENOL) tablet 325 mg	Dose: 325 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer if a grade 1 or 2 infusion related reaction occurs.		  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer if a grade 1 or 2 infusion related reaction occurs.		  	acetaminophen (TYLENOL) tablet 975 mg	Dose: 975 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer if a grade 1 or 2 infusion related reaction occurs.			Chemotherapy
  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	Nivolumab is administered at a flat dose. The dose is 480 mg (administered every 4 weeks +/- 2 days) for up to 1 year total. Nivolumab is to be administered as a 30-minute (+/-5 minutes) IV infusion. The drug can be infused undiluted or diluted with 0.9% normal saline or 5% dextrose for delivery but the total drug concentration of the solution should be between 2mg/mL - 10mg/mL. It is not to be administered as an IV push or bolus injection. At the end of the infusion, flush the line with a sufficient quantity of normal saline. The total infusion volume should not exceed 120 mL.
		  	ONC NURSING COMMUNICATION 8	Interval: --	Occurrences: --	Comments:	If a grade 1 or 2 infusion related reaction occurs, patients may be administered premedication prior to future Nivolumab infusions with diphenhydramine 50 mg and acetaminophen 325 to 1000 mg administered. The Nivolumab should start at least 30 minutes after the start of second premedication.
		  	ONC NURSING COMMUNICATION 9	Interval: --	Occurrences: --	Comments:	All the subsequent cycles for 1 year since first dose of Nivolumab will be similar as Cycle 2.
			Chemotherapy
  	INV-Nivolumab (EA5142/Pro00016419/Bernicker) 10 mg/mL 480 mg in sodium chloride 0.9% 100 mL (4.8 mg/mL) infusion	Dose: 480 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S	End: S		Instructions:	Prepared dose contains open label active Nivolumab. Administer intravenously via pump, using 0.2 to 1.2 micron inline filter, over 30 minutes. Stability of prepared dose: Room temperature, including infusion time: 4 hours. Refrigerated: 20 hours.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-NIVOLUMAB VIAL (EA5142/PRO00016419/BERNICKER)	Medications	480 mg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	52 mL	Yes	Yes				Discharge Nursing Orders
  	ONC NURSING COMMUNICATION 76	Interval: --	Occurrences: --	Comments:	Discontinue IV.
			Discharge Nursing Orders
☑	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN					☑	HEParin, porcine (PF) injection 500 Units	Dose: 500 Units	Route: intra-catheter	once PRN	Start: S			Instructions:	Concentration: 100 units/mL. Heparin flush for Implanted Vascular Access Device maintenance.					
Cycle 4	Repeat 1 time	Cycle length: 28 days	Day 1 (Infusion day)	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Line Care
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Nursing Orders
  	VITAL SIGNS - T/P/R/BP	Interval: --	Occurrences: --	Comments:	Pre-dose:  Blood pressure, body temperature, heart rate
		  	RESEARCH - MEASURE WEIGHT	Interval: --	Occurrences: --	Comments:	Pre-dose
		  	ONC NURSING COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	ECOG performance status
			Labs
  	HCG QUALITATIVE, SERUM SCREEN	Interval: --	Occurrences: --	Comments:	Only for women of childbearing potential
		  	HCG QUANTITATIVE, SERUM	Interval: --	Occurrences: --	Comments:	Only for women of childbearing potential
		  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		  	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		  	THYROID STIMULATING HORMONE	Interval: --	Occurrences: --		  	T3, FREE	Interval: --	Occurrences: --	Comments:	Only If TSH is abnormal
		  	T4, FREE	Interval: --	Occurrences: --	Comments:	Only If TSH is abnormal
			Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: --	Occurrences: --	Comments:	Grade 1 - MILD Symptoms (cutaneous and subcutaneous symptoms only - itching, flushing, periorbital edema, rash, or runny nose)
1. Stop the infusion.
2. Place the patient on continuous monitoring.
3. Obtain vital signs.
4. Administer Normal Saline at 50 mL per hour using a new bag and new intravenous tubing.
5. If greater than or equal to 30 minutes since the last dose of Diphenhydramine, administer Diphenhydramine 25 mg intravenous once.
6. If less than 30 minutes since the last dose of Diphenhydramine, administer Cetirizine 10 mg orally and Famotidine 20 mg intravenous once.
7. Notify the treating physician.
8. If no improvement after 15 minutes, advance level of care to Grade 2 (Moderate) or Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 4	Interval: --	Occurrences: --	Comments:	Grade 2 - MODERATE Symptoms (cardiovascular, respiratory, or gastrointestinal symptoms - shortness of breath, wheezing, nausea, vomiting, dizziness, diaphoresis, throat or chest tightness, abdominal or back pain)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
6. Administer Normal Saline at 150 mL per hour using a new bag and new intravenous tubing.
7. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous), Cetirizine 10 mg orally and Famotidine 20 mg intravenous once.
8. If no improvement after 15 minutes, advance level of care to Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 83	Interval: --	Occurrences: --	Comments:	Grade 3 – SEVERE Symptoms (hypoxia, hypotension, or neurologic compromise – cyanosis or O2 saturation less than 92%, hypotension with systolic blood pressure less than 90 mmHg, confusion, collapse, loss of consciousness, or incontinence)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. If heart rate is less than 50 or greater than 120, or blood pressure is less than 90/50 mmHg, place patient in reclined or flattened position.
6. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
7. Administer Normal Saline at 1000 mL intravenous bolus using a new bag and new intravenous tubing.
8. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous) and Famotidine 20 mg intravenous once.
9. Administer Epinephrine (1:1000) 0.3 mg subcutaneous.
10. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	PRN	Start: S				  	cetirizine (ZyrTEC) tablet 10 mg	Dose: 10 mg	Route: oral	once PRN	Start: S				  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	PRN	Start: S				  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	PRN					  	dexAMETHasone (DECADRON) IV 4 mg	Dose: 4 mg	Route: intravenous	PRN					  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					Pre-Medications
  	diphenhydrAMINE (BENADRYL) injection 50 mg	Dose: 50 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer if a grade 1 or 2 infusion related reaction occurs.		  	acetaminophen (TYLENOL) tablet 325 mg	Dose: 325 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer if a grade 1 or 2 infusion related reaction occurs.		  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer if a grade 1 or 2 infusion related reaction occurs.		  	acetaminophen (TYLENOL) tablet 975 mg	Dose: 975 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer if a grade 1 or 2 infusion related reaction occurs.			Chemotherapy
  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	Nivolumab is administered at a flat dose. The dose is 480 mg (administered every 4 weeks +/- 2 days) for up to 1 year total. Nivolumab is to be administered as a 30-minute (+/-5 minutes) IV infusion. The drug can be infused undiluted or diluted with 0.9% normal saline or 5% dextrose for delivery but the total drug concentration of the solution should be between 2mg/mL - 10mg/mL. It is not to be administered as an IV push or bolus injection. At the end of the infusion, flush the line with a sufficient quantity of normal saline. The total infusion volume should not exceed 120 mL.
		  	ONC NURSING COMMUNICATION 8	Interval: --	Occurrences: --	Comments:	If a grade 1 or 2 infusion related reaction occurs, patients may be administered premedication prior to future Nivolumab infusions with diphenhydramine 50 mg and acetaminophen 325 to 1000 mg administered. The Nivolumab should start at least 30 minutes after the start of second premedication.
		  	ONC NURSING COMMUNICATION 9	Interval: --	Occurrences: --	Comments:	All the subsequent cycles for 1 year since first dose of Nivolumab will be similar as Cycle 2.
			Chemotherapy
  	INV-Nivolumab (EA5142/Pro00016419/Bernicker) 10 mg/mL 480 mg in sodium chloride 0.9% 100 mL (4.8 mg/mL) infusion	Dose: 480 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S	End: S		Instructions:	Prepared dose contains open label active Nivolumab. Administer intravenously via pump, using 0.2 to 1.2 micron inline filter, over 30 minutes. Stability of prepared dose: Room temperature, including infusion time: 4 hours. Refrigerated: 20 hours.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-NIVOLUMAB VIAL (EA5142/PRO00016419/BERNICKER)	Medications	480 mg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	52 mL	Yes	Yes				Discharge Nursing Orders
  	ONC NURSING COMMUNICATION 76	Interval: --	Occurrences: --	Comments:	Discontinue IV.
			Discharge Nursing Orders
☑	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN					☑	HEParin, porcine (PF) injection 500 Units	Dose: 500 Units	Route: intra-catheter	once PRN	Start: S			Instructions:	Concentration: 100 units/mL. Heparin flush for Implanted Vascular Access Device maintenance.					
Cycle 5	Repeat 1 time	Cycle length: 28 days	Day 1 (Infusion day)	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Line Care
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Nursing Orders
  	VITAL SIGNS - T/P/R/BP	Interval: --	Occurrences: --	Comments:	Pre-dose:  Blood pressure, body temperature, heart rate
		  	RESEARCH - MEASURE WEIGHT	Interval: --	Occurrences: --	Comments:	Pre-dose
		  	ONC NURSING COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	ECOG performance status
			Labs
  	HCG QUALITATIVE, SERUM SCREEN	Interval: --	Occurrences: --	Comments:	Only for women of childbearing potential
		  	HCG QUANTITATIVE, SERUM	Interval: --	Occurrences: --	Comments:	Only for women of childbearing potential
		  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		  	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		  	THYROID STIMULATING HORMONE	Interval: --	Occurrences: --		  	T3, FREE	Interval: --	Occurrences: --	Comments:	Only If TSH is abnormal
		  	T4, FREE	Interval: --	Occurrences: --	Comments:	Only If TSH is abnormal
			Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: --	Occurrences: --	Comments:	Grade 1 - MILD Symptoms (cutaneous and subcutaneous symptoms only - itching, flushing, periorbital edema, rash, or runny nose)
1. Stop the infusion.
2. Place the patient on continuous monitoring.
3. Obtain vital signs.
4. Administer Normal Saline at 50 mL per hour using a new bag and new intravenous tubing.
5. If greater than or equal to 30 minutes since the last dose of Diphenhydramine, administer Diphenhydramine 25 mg intravenous once.
6. If less than 30 minutes since the last dose of Diphenhydramine, administer Cetirizine 10 mg orally and Famotidine 20 mg intravenous once.
7. Notify the treating physician.
8. If no improvement after 15 minutes, advance level of care to Grade 2 (Moderate) or Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 4	Interval: --	Occurrences: --	Comments:	Grade 2 - MODERATE Symptoms (cardiovascular, respiratory, or gastrointestinal symptoms - shortness of breath, wheezing, nausea, vomiting, dizziness, diaphoresis, throat or chest tightness, abdominal or back pain)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
6. Administer Normal Saline at 150 mL per hour using a new bag and new intravenous tubing.
7. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous), Cetirizine 10 mg orally and Famotidine 20 mg intravenous once.
8. If no improvement after 15 minutes, advance level of care to Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 83	Interval: --	Occurrences: --	Comments:	Grade 3 – SEVERE Symptoms (hypoxia, hypotension, or neurologic compromise – cyanosis or O2 saturation less than 92%, hypotension with systolic blood pressure less than 90 mmHg, confusion, collapse, loss of consciousness, or incontinence)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. If heart rate is less than 50 or greater than 120, or blood pressure is less than 90/50 mmHg, place patient in reclined or flattened position.
6. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
7. Administer Normal Saline at 1000 mL intravenous bolus using a new bag and new intravenous tubing.
8. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous) and Famotidine 20 mg intravenous once.
9. Administer Epinephrine (1:1000) 0.3 mg subcutaneous.
10. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	PRN	Start: S				  	cetirizine (ZyrTEC) tablet 10 mg	Dose: 10 mg	Route: oral	once PRN	Start: S				  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	PRN	Start: S				  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	PRN					  	dexAMETHasone (DECADRON) IV 4 mg	Dose: 4 mg	Route: intravenous	PRN					  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					Pre-Medications
  	diphenhydrAMINE (BENADRYL) injection 50 mg	Dose: 50 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer if a grade 1 or 2 infusion related reaction occurs.		  	acetaminophen (TYLENOL) tablet 325 mg	Dose: 325 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer if a grade 1 or 2 infusion related reaction occurs.		  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer if a grade 1 or 2 infusion related reaction occurs.		  	acetaminophen (TYLENOL) tablet 975 mg	Dose: 975 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer if a grade 1 or 2 infusion related reaction occurs.			Chemotherapy
  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	Nivolumab is administered at a flat dose. The dose is 480 mg (administered every 4 weeks +/- 2 days) for up to 1 year total. Nivolumab is to be administered as a 30-minute (+/-5 minutes) IV infusion. The drug can be infused undiluted or diluted with 0.9% normal saline or 5% dextrose for delivery but the total drug concentration of the solution should be between 2mg/mL - 10mg/mL. It is not to be administered as an IV push or bolus injection. At the end of the infusion, flush the line with a sufficient quantity of normal saline. The total infusion volume should not exceed 120 mL.
		  	ONC NURSING COMMUNICATION 8	Interval: --	Occurrences: --	Comments:	If a grade 1 or 2 infusion related reaction occurs, patients may be administered premedication prior to future Nivolumab infusions with diphenhydramine 50 mg and acetaminophen 325 to 1000 mg administered. The Nivolumab should start at least 30 minutes after the start of second premedication.
		  	ONC NURSING COMMUNICATION 9	Interval: --	Occurrences: --	Comments:	All the subsequent cycles for 1 year since first dose of Nivolumab will be similar as Cycle 2.
			Chemotherapy
  	INV-Nivolumab (EA5142/Pro00016419/Bernicker) 10 mg/mL 480 mg in sodium chloride 0.9% 100 mL (4.8 mg/mL) infusion	Dose: 480 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S	End: S		Instructions:	Prepared dose contains open label active Nivolumab. Administer intravenously via pump, using 0.2 to 1.2 micron inline filter, over 30 minutes. Stability of prepared dose: Room temperature, including infusion time: 4 hours. Refrigerated: 20 hours.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-NIVOLUMAB VIAL (EA5142/PRO00016419/BERNICKER)	Medications	480 mg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	52 mL	Yes	Yes				Discharge Nursing Orders
  	ONC NURSING COMMUNICATION 76	Interval: --	Occurrences: --	Comments:	Discontinue IV.
			Discharge Nursing Orders
☑	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN					☑	HEParin, porcine (PF) injection 500 Units	Dose: 500 Units	Route: intra-catheter	once PRN	Start: S			Instructions:	Concentration: 100 units/mL. Heparin flush for Implanted Vascular Access Device maintenance.					
Cycle 6	Repeat 1 time	Cycle length: 28 days	Day 1 (Infusion day)	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Line Care
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Nursing Orders
  	VITAL SIGNS - T/P/R/BP	Interval: --	Occurrences: --	Comments:	Pre-dose:  Blood pressure, body temperature, heart rate
		  	RESEARCH - MEASURE WEIGHT	Interval: --	Occurrences: --	Comments:	Pre-dose
		  	ONC NURSING COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	ECOG performance status
			Labs
  	HCG QUALITATIVE, SERUM SCREEN	Interval: --	Occurrences: --	Comments:	Only for women of childbearing potential
		  	HCG QUANTITATIVE, SERUM	Interval: --	Occurrences: --	Comments:	Only for women of childbearing potential
		  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		  	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		  	THYROID STIMULATING HORMONE	Interval: --	Occurrences: --		  	T3, FREE	Interval: --	Occurrences: --	Comments:	Only If TSH is abnormal
		  	T4, FREE	Interval: --	Occurrences: --	Comments:	Only If TSH is abnormal
			Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: --	Occurrences: --	Comments:	Grade 1 - MILD Symptoms (cutaneous and subcutaneous symptoms only - itching, flushing, periorbital edema, rash, or runny nose)
1. Stop the infusion.
2. Place the patient on continuous monitoring.
3. Obtain vital signs.
4. Administer Normal Saline at 50 mL per hour using a new bag and new intravenous tubing.
5. If greater than or equal to 30 minutes since the last dose of Diphenhydramine, administer Diphenhydramine 25 mg intravenous once.
6. If less than 30 minutes since the last dose of Diphenhydramine, administer Cetirizine 10 mg orally and Famotidine 20 mg intravenous once.
7. Notify the treating physician.
8. If no improvement after 15 minutes, advance level of care to Grade 2 (Moderate) or Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 4	Interval: --	Occurrences: --	Comments:	Grade 2 - MODERATE Symptoms (cardiovascular, respiratory, or gastrointestinal symptoms - shortness of breath, wheezing, nausea, vomiting, dizziness, diaphoresis, throat or chest tightness, abdominal or back pain)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
6. Administer Normal Saline at 150 mL per hour using a new bag and new intravenous tubing.
7. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous), Cetirizine 10 mg orally and Famotidine 20 mg intravenous once.
8. If no improvement after 15 minutes, advance level of care to Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 83	Interval: --	Occurrences: --	Comments:	Grade 3 – SEVERE Symptoms (hypoxia, hypotension, or neurologic compromise – cyanosis or O2 saturation less than 92%, hypotension with systolic blood pressure less than 90 mmHg, confusion, collapse, loss of consciousness, or incontinence)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. If heart rate is less than 50 or greater than 120, or blood pressure is less than 90/50 mmHg, place patient in reclined or flattened position.
6. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
7. Administer Normal Saline at 1000 mL intravenous bolus using a new bag and new intravenous tubing.
8. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous) and Famotidine 20 mg intravenous once.
9. Administer Epinephrine (1:1000) 0.3 mg subcutaneous.
10. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	PRN	Start: S				  	cetirizine (ZyrTEC) tablet 10 mg	Dose: 10 mg	Route: oral	once PRN	Start: S				  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	PRN	Start: S				  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	PRN					  	dexAMETHasone (DECADRON) IV 4 mg	Dose: 4 mg	Route: intravenous	PRN					  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					Pre-Medications
  	diphenhydrAMINE (BENADRYL) injection 50 mg	Dose: 50 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer if a grade 1 or 2 infusion related reaction occurs.		  	acetaminophen (TYLENOL) tablet 325 mg	Dose: 325 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer if a grade 1 or 2 infusion related reaction occurs.		  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer if a grade 1 or 2 infusion related reaction occurs.		  	acetaminophen (TYLENOL) tablet 975 mg	Dose: 975 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer if a grade 1 or 2 infusion related reaction occurs.			Chemotherapy
  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	Nivolumab is administered at a flat dose. The dose is 480 mg (administered every 4 weeks +/- 2 days) for up to 1 year total. Nivolumab is to be administered as a 30-minute (+/-5 minutes) IV infusion. The drug can be infused undiluted or diluted with 0.9% normal saline or 5% dextrose for delivery but the total drug concentration of the solution should be between 2mg/mL - 10mg/mL. It is not to be administered as an IV push or bolus injection. At the end of the infusion, flush the line with a sufficient quantity of normal saline. The total infusion volume should not exceed 120 mL.
		  	ONC NURSING COMMUNICATION 8	Interval: --	Occurrences: --	Comments:	If a grade 1 or 2 infusion related reaction occurs, patients may be administered premedication prior to future Nivolumab infusions with diphenhydramine 50 mg and acetaminophen 325 to 1000 mg administered. The Nivolumab should start at least 30 minutes after the start of second premedication.
		  	ONC NURSING COMMUNICATION 9	Interval: --	Occurrences: --	Comments:	All the subsequent cycles for 1 year since first dose of Nivolumab will be similar as Cycle 2.
			Chemotherapy
  	INV-Nivolumab (EA5142/Pro00016419/Bernicker) 10 mg/mL 480 mg in sodium chloride 0.9% 100 mL (4.8 mg/mL) infusion	Dose: 480 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S	End: S		Instructions:	Prepared dose contains open label active Nivolumab. Administer intravenously via pump, using 0.2 to 1.2 micron inline filter, over 30 minutes. Stability of prepared dose: Room temperature, including infusion time: 4 hours. Refrigerated: 20 hours.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-NIVOLUMAB VIAL (EA5142/PRO00016419/BERNICKER)	Medications	480 mg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	52 mL	Yes	Yes				Discharge Nursing Orders
  	ONC NURSING COMMUNICATION 76	Interval: --	Occurrences: --	Comments:	Discontinue IV.
			Discharge Nursing Orders
☑	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN					☑	HEParin, porcine (PF) injection 500 Units	Dose: 500 Units	Route: intra-catheter	once PRN	Start: S			Instructions:	Concentration: 100 units/mL. Heparin flush for Implanted Vascular Access Device maintenance.					
Cycle 7	Repeat 1 time	Cycle length: 28 days	Day 1 (Infusion day)	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Line Care
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Nursing Orders
  	VITAL SIGNS - T/P/R/BP	Interval: --	Occurrences: --	Comments:	Pre-dose:  Blood pressure, body temperature, heart rate
		  	RESEARCH - MEASURE WEIGHT	Interval: --	Occurrences: --	Comments:	Pre-dose
		  	ONC NURSING COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	ECOG performance status
			Imaging
  	CT CHEST W WO CONTRAST	Interval: --	Occurrences: --	Comments:	Including adrenals (within 1 month of randomization and every 6 months)
			Labs
  	HCG QUALITATIVE, SERUM SCREEN	Interval: --	Occurrences: --	Comments:	Only for women of childbearing potential
		  	HCG QUANTITATIVE, SERUM	Interval: --	Occurrences: --	Comments:	Only for women of childbearing potential
		  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		  	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		  	THYROID STIMULATING HORMONE	Interval: --	Occurrences: --		  	T3, FREE	Interval: --	Occurrences: --	Comments:	Only If TSH is abnormal
		  	T4, FREE	Interval: --	Occurrences: --	Comments:	Only If TSH is abnormal
			Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: --	Occurrences: --	Comments:	Grade 1 - MILD Symptoms (cutaneous and subcutaneous symptoms only - itching, flushing, periorbital edema, rash, or runny nose)
1. Stop the infusion.
2. Place the patient on continuous monitoring.
3. Obtain vital signs.
4. Administer Normal Saline at 50 mL per hour using a new bag and new intravenous tubing.
5. If greater than or equal to 30 minutes since the last dose of Diphenhydramine, administer Diphenhydramine 25 mg intravenous once.
6. If less than 30 minutes since the last dose of Diphenhydramine, administer Cetirizine 10 mg orally and Famotidine 20 mg intravenous once.
7. Notify the treating physician.
8. If no improvement after 15 minutes, advance level of care to Grade 2 (Moderate) or Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 4	Interval: --	Occurrences: --	Comments:	Grade 2 - MODERATE Symptoms (cardiovascular, respiratory, or gastrointestinal symptoms - shortness of breath, wheezing, nausea, vomiting, dizziness, diaphoresis, throat or chest tightness, abdominal or back pain)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
6. Administer Normal Saline at 150 mL per hour using a new bag and new intravenous tubing.
7. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous), Cetirizine 10 mg orally and Famotidine 20 mg intravenous once.
8. If no improvement after 15 minutes, advance level of care to Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 83	Interval: --	Occurrences: --	Comments:	Grade 3 – SEVERE Symptoms (hypoxia, hypotension, or neurologic compromise – cyanosis or O2 saturation less than 92%, hypotension with systolic blood pressure less than 90 mmHg, confusion, collapse, loss of consciousness, or incontinence)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. If heart rate is less than 50 or greater than 120, or blood pressure is less than 90/50 mmHg, place patient in reclined or flattened position.
6. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
7. Administer Normal Saline at 1000 mL intravenous bolus using a new bag and new intravenous tubing.
8. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous) and Famotidine 20 mg intravenous once.
9. Administer Epinephrine (1:1000) 0.3 mg subcutaneous.
10. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	PRN	Start: S				  	cetirizine (ZyrTEC) tablet 10 mg	Dose: 10 mg	Route: oral	once PRN	Start: S				  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	PRN	Start: S				  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	PRN					  	dexAMETHasone (DECADRON) IV 4 mg	Dose: 4 mg	Route: intravenous	PRN					  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					Pre-Medications
  	diphenhydrAMINE (BENADRYL) injection 50 mg	Dose: 50 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer if a grade 1 or 2 infusion related reaction occurs.		  	acetaminophen (TYLENOL) tablet 325 mg	Dose: 325 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer if a grade 1 or 2 infusion related reaction occurs.		  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer if a grade 1 or 2 infusion related reaction occurs.		  	acetaminophen (TYLENOL) tablet 975 mg	Dose: 975 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer if a grade 1 or 2 infusion related reaction occurs.			Chemotherapy
  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	Nivolumab is administered at a flat dose. The dose is 480 mg (administered every 4 weeks +/- 2 days) for up to 1 year total. Nivolumab is to be administered as a 30-minute (+/-5 minutes) IV infusion. The drug can be infused undiluted or diluted with 0.9% normal saline or 5% dextrose for delivery but the total drug concentration of the solution should be between 2mg/mL - 10mg/mL. It is not to be administered as an IV push or bolus injection. At the end of the infusion, flush the line with a sufficient quantity of normal saline. The total infusion volume should not exceed 120 mL.
		  	ONC NURSING COMMUNICATION 8	Interval: --	Occurrences: --	Comments:	If a grade 1 or 2 infusion related reaction occurs, patients may be administered premedication prior to future Nivolumab infusions with diphenhydramine 50 mg and acetaminophen 325 to 1000 mg administered. The Nivolumab should start at least 30 minutes after the start of second premedication.
		  	ONC NURSING COMMUNICATION 9	Interval: --	Occurrences: --	Comments:	All the subsequent cycles for 1 year since first dose of Nivolumab will be similar as Cycle 2.
			Chemotherapy
  	INV-Nivolumab (EA5142/Pro00016419/Bernicker) 10 mg/mL 480 mg in sodium chloride 0.9% 100 mL (4.8 mg/mL) infusion	Dose: 480 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S	End: S		Instructions:	Prepared dose contains open label active Nivolumab. Administer intravenously via pump, using 0.2 to 1.2 micron inline filter, over 30 minutes. Stability of prepared dose: Room temperature, including infusion time: 4 hours. Refrigerated: 20 hours.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-NIVOLUMAB VIAL (EA5142/PRO00016419/BERNICKER)	Medications	480 mg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	52 mL	Yes	Yes				Discharge Nursing Orders
  	ONC NURSING COMMUNICATION 76	Interval: --	Occurrences: --	Comments:	Discontinue IV.
			Discharge Nursing Orders
☑	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN					☑	HEParin, porcine (PF) injection 500 Units	Dose: 500 Units	Route: intra-catheter	once PRN	Start: S			Instructions:	Concentration: 100 units/mL. Heparin flush for Implanted Vascular Access Device maintenance.					
Cycle 8	Repeat 1 time	Cycle length: 28 days	Day 1 (Infusion day)	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Line Care
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Nursing Orders
  	VITAL SIGNS - T/P/R/BP	Interval: --	Occurrences: --	Comments:	Pre-dose:  Blood pressure, body temperature, heart rate
		  	RESEARCH - MEASURE WEIGHT	Interval: --	Occurrences: --	Comments:	Pre-dose
		  	ONC NURSING COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	ECOG performance status
			Labs
  	HCG QUALITATIVE, SERUM SCREEN	Interval: --	Occurrences: --	Comments:	Only for women of childbearing potential
		  	HCG QUANTITATIVE, SERUM	Interval: --	Occurrences: --	Comments:	Only for women of childbearing potential
		  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		  	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		  	THYROID STIMULATING HORMONE	Interval: --	Occurrences: --		  	T3, FREE	Interval: --	Occurrences: --	Comments:	Only If TSH is abnormal
		  	T4, FREE	Interval: --	Occurrences: --	Comments:	Only If TSH is abnormal
			Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: --	Occurrences: --	Comments:	Grade 1 - MILD Symptoms (cutaneous and subcutaneous symptoms only - itching, flushing, periorbital edema, rash, or runny nose)
1. Stop the infusion.
2. Place the patient on continuous monitoring.
3. Obtain vital signs.
4. Administer Normal Saline at 50 mL per hour using a new bag and new intravenous tubing.
5. If greater than or equal to 30 minutes since the last dose of Diphenhydramine, administer Diphenhydramine 25 mg intravenous once.
6. If less than 30 minutes since the last dose of Diphenhydramine, administer Cetirizine 10 mg orally and Famotidine 20 mg intravenous once.
7. Notify the treating physician.
8. If no improvement after 15 minutes, advance level of care to Grade 2 (Moderate) or Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 4	Interval: --	Occurrences: --	Comments:	Grade 2 - MODERATE Symptoms (cardiovascular, respiratory, or gastrointestinal symptoms - shortness of breath, wheezing, nausea, vomiting, dizziness, diaphoresis, throat or chest tightness, abdominal or back pain)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
6. Administer Normal Saline at 150 mL per hour using a new bag and new intravenous tubing.
7. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous), Cetirizine 10 mg orally and Famotidine 20 mg intravenous once.
8. If no improvement after 15 minutes, advance level of care to Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 83	Interval: --	Occurrences: --	Comments:	Grade 3 – SEVERE Symptoms (hypoxia, hypotension, or neurologic compromise – cyanosis or O2 saturation less than 92%, hypotension with systolic blood pressure less than 90 mmHg, confusion, collapse, loss of consciousness, or incontinence)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. If heart rate is less than 50 or greater than 120, or blood pressure is less than 90/50 mmHg, place patient in reclined or flattened position.
6. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
7. Administer Normal Saline at 1000 mL intravenous bolus using a new bag and new intravenous tubing.
8. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous) and Famotidine 20 mg intravenous once.
9. Administer Epinephrine (1:1000) 0.3 mg subcutaneous.
10. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	PRN	Start: S				  	cetirizine (ZyrTEC) tablet 10 mg	Dose: 10 mg	Route: oral	once PRN	Start: S				  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	PRN	Start: S				  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	PRN					  	dexAMETHasone (DECADRON) IV 4 mg	Dose: 4 mg	Route: intravenous	PRN					  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					Pre-Medications
  	diphenhydrAMINE (BENADRYL) injection 50 mg	Dose: 50 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer if a grade 1 or 2 infusion related reaction occurs.		  	acetaminophen (TYLENOL) tablet 325 mg	Dose: 325 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer if a grade 1 or 2 infusion related reaction occurs.		  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer if a grade 1 or 2 infusion related reaction occurs.		  	acetaminophen (TYLENOL) tablet 975 mg	Dose: 975 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer if a grade 1 or 2 infusion related reaction occurs.			Chemotherapy
  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	Nivolumab is administered at a flat dose. The dose is 480 mg (administered every 4 weeks +/- 2 days) for up to 1 year total. Nivolumab is to be administered as a 30-minute (+/-5 minutes) IV infusion. The drug can be infused undiluted or diluted with 0.9% normal saline or 5% dextrose for delivery but the total drug concentration of the solution should be between 2mg/mL - 10mg/mL. It is not to be administered as an IV push or bolus injection. At the end of the infusion, flush the line with a sufficient quantity of normal saline. The total infusion volume should not exceed 120 mL.
		  	ONC NURSING COMMUNICATION 8	Interval: --	Occurrences: --	Comments:	If a grade 1 or 2 infusion related reaction occurs, patients may be administered premedication prior to future Nivolumab infusions with diphenhydramine 50 mg and acetaminophen 325 to 1000 mg administered. The Nivolumab should start at least 30 minutes after the start of second premedication.
		  	ONC NURSING COMMUNICATION 9	Interval: --	Occurrences: --	Comments:	All the subsequent cycles for 1 year since first dose of Nivolumab will be similar as Cycle 2.
			Chemotherapy
  	INV-Nivolumab (EA5142/Pro00016419/Bernicker) 10 mg/mL 480 mg in sodium chloride 0.9% 100 mL (4.8 mg/mL) infusion	Dose: 480 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S	End: S		Instructions:	Prepared dose contains open label active Nivolumab. Administer intravenously via pump, using 0.2 to 1.2 micron inline filter, over 30 minutes. Stability of prepared dose: Room temperature, including infusion time: 4 hours. Refrigerated: 20 hours.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-NIVOLUMAB VIAL (EA5142/PRO00016419/BERNICKER)	Medications	480 mg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	52 mL	Yes	Yes				Discharge Nursing Orders
  	ONC NURSING COMMUNICATION 76	Interval: --	Occurrences: --	Comments:	Discontinue IV.
			Discharge Nursing Orders
☑	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN					☑	HEParin, porcine (PF) injection 500 Units	Dose: 500 Units	Route: intra-catheter	once PRN	Start: S			Instructions:	Concentration: 100 units/mL. Heparin flush for Implanted Vascular Access Device maintenance.					
Cycle 9	Repeat 1 time	Cycle length: 28 days	Day 1 (Infusion day)	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Line Care
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Nursing Orders
  	VITAL SIGNS - T/P/R/BP	Interval: --	Occurrences: --	Comments:	Pre-dose:  Blood pressure, body temperature, heart rate
		  	RESEARCH - MEASURE WEIGHT	Interval: --	Occurrences: --	Comments:	Pre-dose
		  	ONC NURSING COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	ECOG performance status
			Labs
  	HCG QUALITATIVE, SERUM SCREEN	Interval: --	Occurrences: --	Comments:	Only for women of childbearing potential
		  	HCG QUANTITATIVE, SERUM	Interval: --	Occurrences: --	Comments:	Only for women of childbearing potential
		  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		  	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		  	THYROID STIMULATING HORMONE	Interval: --	Occurrences: --		  	T3, FREE	Interval: --	Occurrences: --	Comments:	Only If TSH is abnormal
		  	T4, FREE	Interval: --	Occurrences: --	Comments:	Only If TSH is abnormal
			Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: --	Occurrences: --	Comments:	Grade 1 - MILD Symptoms (cutaneous and subcutaneous symptoms only - itching, flushing, periorbital edema, rash, or runny nose)
1. Stop the infusion.
2. Place the patient on continuous monitoring.
3. Obtain vital signs.
4. Administer Normal Saline at 50 mL per hour using a new bag and new intravenous tubing.
5. If greater than or equal to 30 minutes since the last dose of Diphenhydramine, administer Diphenhydramine 25 mg intravenous once.
6. If less than 30 minutes since the last dose of Diphenhydramine, administer Cetirizine 10 mg orally and Famotidine 20 mg intravenous once.
7. Notify the treating physician.
8. If no improvement after 15 minutes, advance level of care to Grade 2 (Moderate) or Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 4	Interval: --	Occurrences: --	Comments:	Grade 2 - MODERATE Symptoms (cardiovascular, respiratory, or gastrointestinal symptoms - shortness of breath, wheezing, nausea, vomiting, dizziness, diaphoresis, throat or chest tightness, abdominal or back pain)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
6. Administer Normal Saline at 150 mL per hour using a new bag and new intravenous tubing.
7. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous), Cetirizine 10 mg orally and Famotidine 20 mg intravenous once.
8. If no improvement after 15 minutes, advance level of care to Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 83	Interval: --	Occurrences: --	Comments:	Grade 3 – SEVERE Symptoms (hypoxia, hypotension, or neurologic compromise – cyanosis or O2 saturation less than 92%, hypotension with systolic blood pressure less than 90 mmHg, confusion, collapse, loss of consciousness, or incontinence)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. If heart rate is less than 50 or greater than 120, or blood pressure is less than 90/50 mmHg, place patient in reclined or flattened position.
6. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
7. Administer Normal Saline at 1000 mL intravenous bolus using a new bag and new intravenous tubing.
8. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous) and Famotidine 20 mg intravenous once.
9. Administer Epinephrine (1:1000) 0.3 mg subcutaneous.
10. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	PRN	Start: S				  	cetirizine (ZyrTEC) tablet 10 mg	Dose: 10 mg	Route: oral	once PRN	Start: S				  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	PRN	Start: S				  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	PRN					  	dexAMETHasone (DECADRON) IV 4 mg	Dose: 4 mg	Route: intravenous	PRN					  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					Pre-Medications
  	diphenhydrAMINE (BENADRYL) injection 50 mg	Dose: 50 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer if a grade 1 or 2 infusion related reaction occurs.		  	acetaminophen (TYLENOL) tablet 325 mg	Dose: 325 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer if a grade 1 or 2 infusion related reaction occurs.		  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer if a grade 1 or 2 infusion related reaction occurs.		  	acetaminophen (TYLENOL) tablet 975 mg	Dose: 975 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer if a grade 1 or 2 infusion related reaction occurs.			Chemotherapy
  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	Nivolumab is administered at a flat dose. The dose is 480 mg (administered every 4 weeks +/- 2 days) for up to 1 year total. Nivolumab is to be administered as a 30-minute (+/-5 minutes) IV infusion. The drug can be infused undiluted or diluted with 0.9% normal saline or 5% dextrose for delivery but the total drug concentration of the solution should be between 2mg/mL - 10mg/mL. It is not to be administered as an IV push or bolus injection. At the end of the infusion, flush the line with a sufficient quantity of normal saline. The total infusion volume should not exceed 120 mL.
		  	ONC NURSING COMMUNICATION 8	Interval: --	Occurrences: --	Comments:	If a grade 1 or 2 infusion related reaction occurs, patients may be administered premedication prior to future Nivolumab infusions with diphenhydramine 50 mg and acetaminophen 325 to 1000 mg administered. The Nivolumab should start at least 30 minutes after the start of second premedication.
		  	ONC NURSING COMMUNICATION 9	Interval: --	Occurrences: --	Comments:	All the subsequent cycles for 1 year since first dose of Nivolumab will be similar as Cycle 2.
			Chemotherapy
  	INV-Nivolumab (EA5142/Pro00016419/Bernicker) 10 mg/mL 480 mg in sodium chloride 0.9% 100 mL (4.8 mg/mL) infusion	Dose: 480 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S	End: S		Instructions:	Prepared dose contains open label active Nivolumab. Administer intravenously via pump, using 0.2 to 1.2 micron inline filter, over 30 minutes. Stability of prepared dose: Room temperature, including infusion time: 4 hours. Refrigerated: 20 hours.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-NIVOLUMAB VIAL (EA5142/PRO00016419/BERNICKER)	Medications	480 mg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	52 mL	Yes	Yes				Discharge Nursing Orders
  	ONC NURSING COMMUNICATION 76	Interval: --	Occurrences: --	Comments:	Discontinue IV.
			Discharge Nursing Orders
☑	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN					☑	HEParin, porcine (PF) injection 500 Units	Dose: 500 Units	Route: intra-catheter	once PRN	Start: S			Instructions:	Concentration: 100 units/mL. Heparin flush for Implanted Vascular Access Device maintenance.					
Cycle 10	Repeat 1 time	Cycle length: 28 days	Day 1 (Infusion day)	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Line Care
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Nursing Orders
  	VITAL SIGNS - T/P/R/BP	Interval: --	Occurrences: --	Comments:	Pre-dose:  Blood pressure, body temperature, heart rate
		  	RESEARCH - MEASURE WEIGHT	Interval: --	Occurrences: --	Comments:	Pre-dose
		  	ONC NURSING COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	ECOG performance status
			Labs
  	HCG QUALITATIVE, SERUM SCREEN	Interval: --	Occurrences: --	Comments:	Only for women of childbearing potential
		  	HCG QUANTITATIVE, SERUM	Interval: --	Occurrences: --	Comments:	Only for women of childbearing potential
		  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		  	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		  	THYROID STIMULATING HORMONE	Interval: --	Occurrences: --		  	T3, FREE	Interval: --	Occurrences: --	Comments:	Only If TSH is abnormal
		  	T4, FREE	Interval: --	Occurrences: --	Comments:	Only If TSH is abnormal
			Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: --	Occurrences: --	Comments:	Grade 1 - MILD Symptoms (cutaneous and subcutaneous symptoms only - itching, flushing, periorbital edema, rash, or runny nose)
1. Stop the infusion.
2. Place the patient on continuous monitoring.
3. Obtain vital signs.
4. Administer Normal Saline at 50 mL per hour using a new bag and new intravenous tubing.
5. If greater than or equal to 30 minutes since the last dose of Diphenhydramine, administer Diphenhydramine 25 mg intravenous once.
6. If less than 30 minutes since the last dose of Diphenhydramine, administer Cetirizine 10 mg orally and Famotidine 20 mg intravenous once.
7. Notify the treating physician.
8. If no improvement after 15 minutes, advance level of care to Grade 2 (Moderate) or Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 4	Interval: --	Occurrences: --	Comments:	Grade 2 - MODERATE Symptoms (cardiovascular, respiratory, or gastrointestinal symptoms - shortness of breath, wheezing, nausea, vomiting, dizziness, diaphoresis, throat or chest tightness, abdominal or back pain)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
6. Administer Normal Saline at 150 mL per hour using a new bag and new intravenous tubing.
7. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous), Cetirizine 10 mg orally and Famotidine 20 mg intravenous once.
8. If no improvement after 15 minutes, advance level of care to Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 83	Interval: --	Occurrences: --	Comments:	Grade 3 – SEVERE Symptoms (hypoxia, hypotension, or neurologic compromise – cyanosis or O2 saturation less than 92%, hypotension with systolic blood pressure less than 90 mmHg, confusion, collapse, loss of consciousness, or incontinence)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. If heart rate is less than 50 or greater than 120, or blood pressure is less than 90/50 mmHg, place patient in reclined or flattened position.
6. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
7. Administer Normal Saline at 1000 mL intravenous bolus using a new bag and new intravenous tubing.
8. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous) and Famotidine 20 mg intravenous once.
9. Administer Epinephrine (1:1000) 0.3 mg subcutaneous.
10. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	PRN	Start: S				  	cetirizine (ZyrTEC) tablet 10 mg	Dose: 10 mg	Route: oral	once PRN	Start: S				  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	PRN	Start: S				  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	PRN					  	dexAMETHasone (DECADRON) IV 4 mg	Dose: 4 mg	Route: intravenous	PRN					  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					Pre-Medications
  	diphenhydrAMINE (BENADRYL) injection 50 mg	Dose: 50 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer if a grade 1 or 2 infusion related reaction occurs.		  	acetaminophen (TYLENOL) tablet 325 mg	Dose: 325 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer if a grade 1 or 2 infusion related reaction occurs.		  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer if a grade 1 or 2 infusion related reaction occurs.		  	acetaminophen (TYLENOL) tablet 975 mg	Dose: 975 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer if a grade 1 or 2 infusion related reaction occurs.			Chemotherapy
  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	Nivolumab is administered at a flat dose. The dose is 480 mg (administered every 4 weeks +/- 2 days) for up to 1 year total. Nivolumab is to be administered as a 30-minute (+/-5 minutes) IV infusion. The drug can be infused undiluted or diluted with 0.9% normal saline or 5% dextrose for delivery but the total drug concentration of the solution should be between 2mg/mL - 10mg/mL. It is not to be administered as an IV push or bolus injection. At the end of the infusion, flush the line with a sufficient quantity of normal saline. The total infusion volume should not exceed 120 mL.
		  	ONC NURSING COMMUNICATION 8	Interval: --	Occurrences: --	Comments:	If a grade 1 or 2 infusion related reaction occurs, patients may be administered premedication prior to future Nivolumab infusions with diphenhydramine 50 mg and acetaminophen 325 to 1000 mg administered. The Nivolumab should start at least 30 minutes after the start of second premedication.
		  	ONC NURSING COMMUNICATION 9	Interval: --	Occurrences: --	Comments:	All the subsequent cycles for 1 year since first dose of Nivolumab will be similar as Cycle 2.
			Chemotherapy
  	INV-Nivolumab (EA5142/Pro00016419/Bernicker) 10 mg/mL 480 mg in sodium chloride 0.9% 100 mL (4.8 mg/mL) infusion	Dose: 480 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S	End: S		Instructions:	Prepared dose contains open label active Nivolumab. Administer intravenously via pump, using 0.2 to 1.2 micron inline filter, over 30 minutes. Stability of prepared dose: Room temperature, including infusion time: 4 hours. Refrigerated: 20 hours.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-NIVOLUMAB VIAL (EA5142/PRO00016419/BERNICKER)	Medications	480 mg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	52 mL	Yes	Yes				Discharge Nursing Orders
  	ONC NURSING COMMUNICATION 76	Interval: --	Occurrences: --	Comments:	Discontinue IV.
			Discharge Nursing Orders
☑	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN					☑	HEParin, porcine (PF) injection 500 Units	Dose: 500 Units	Route: intra-catheter	once PRN	Start: S			Instructions:	Concentration: 100 units/mL. Heparin flush for Implanted Vascular Access Device maintenance.					
Cycle 11	Repeat 1 time	Cycle length: 28 days	Day 1 (Infusion day)	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Line Care
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Nursing Orders
  	VITAL SIGNS - T/P/R/BP	Interval: --	Occurrences: --	Comments:	Pre-dose:  Blood pressure, body temperature, heart rate
		  	RESEARCH - MEASURE WEIGHT	Interval: --	Occurrences: --	Comments:	Pre-dose
		  	ONC NURSING COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	ECOG performance status
			Labs
  	HCG QUALITATIVE, SERUM SCREEN	Interval: --	Occurrences: --	Comments:	Only for women of childbearing potential
		  	HCG QUANTITATIVE, SERUM	Interval: --	Occurrences: --	Comments:	Only for women of childbearing potential
		  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		  	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		  	THYROID STIMULATING HORMONE	Interval: --	Occurrences: --		  	T3, FREE	Interval: --	Occurrences: --	Comments:	Only If TSH is abnormal
		  	T4, FREE	Interval: --	Occurrences: --	Comments:	Only If TSH is abnormal
			Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: --	Occurrences: --	Comments:	Grade 1 - MILD Symptoms (cutaneous and subcutaneous symptoms only - itching, flushing, periorbital edema, rash, or runny nose)
1. Stop the infusion.
2. Place the patient on continuous monitoring.
3. Obtain vital signs.
4. Administer Normal Saline at 50 mL per hour using a new bag and new intravenous tubing.
5. If greater than or equal to 30 minutes since the last dose of Diphenhydramine, administer Diphenhydramine 25 mg intravenous once.
6. If less than 30 minutes since the last dose of Diphenhydramine, administer Cetirizine 10 mg orally and Famotidine 20 mg intravenous once.
7. Notify the treating physician.
8. If no improvement after 15 minutes, advance level of care to Grade 2 (Moderate) or Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 4	Interval: --	Occurrences: --	Comments:	Grade 2 - MODERATE Symptoms (cardiovascular, respiratory, or gastrointestinal symptoms - shortness of breath, wheezing, nausea, vomiting, dizziness, diaphoresis, throat or chest tightness, abdominal or back pain)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
6. Administer Normal Saline at 150 mL per hour using a new bag and new intravenous tubing.
7. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous), Cetirizine 10 mg orally and Famotidine 20 mg intravenous once.
8. If no improvement after 15 minutes, advance level of care to Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 83	Interval: --	Occurrences: --	Comments:	Grade 3 – SEVERE Symptoms (hypoxia, hypotension, or neurologic compromise – cyanosis or O2 saturation less than 92%, hypotension with systolic blood pressure less than 90 mmHg, confusion, collapse, loss of consciousness, or incontinence)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. If heart rate is less than 50 or greater than 120, or blood pressure is less than 90/50 mmHg, place patient in reclined or flattened position.
6. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
7. Administer Normal Saline at 1000 mL intravenous bolus using a new bag and new intravenous tubing.
8. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous) and Famotidine 20 mg intravenous once.
9. Administer Epinephrine (1:1000) 0.3 mg subcutaneous.
10. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	PRN	Start: S				  	cetirizine (ZyrTEC) tablet 10 mg	Dose: 10 mg	Route: oral	once PRN	Start: S				  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	PRN	Start: S				  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	PRN					  	dexAMETHasone (DECADRON) IV 4 mg	Dose: 4 mg	Route: intravenous	PRN					  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					Pre-Medications
  	diphenhydrAMINE (BENADRYL) injection 50 mg	Dose: 50 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer if a grade 1 or 2 infusion related reaction occurs.		  	acetaminophen (TYLENOL) tablet 325 mg	Dose: 325 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer if a grade 1 or 2 infusion related reaction occurs.		  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer if a grade 1 or 2 infusion related reaction occurs.		  	acetaminophen (TYLENOL) tablet 975 mg	Dose: 975 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer if a grade 1 or 2 infusion related reaction occurs.			Chemotherapy
  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	Nivolumab is administered at a flat dose. The dose is 480 mg (administered every 4 weeks +/- 2 days) for up to 1 year total. Nivolumab is to be administered as a 30-minute (+/-5 minutes) IV infusion. The drug can be infused undiluted or diluted with 0.9% normal saline or 5% dextrose for delivery but the total drug concentration of the solution should be between 2mg/mL - 10mg/mL. It is not to be administered as an IV push or bolus injection. At the end of the infusion, flush the line with a sufficient quantity of normal saline. The total infusion volume should not exceed 120 mL.
		  	ONC NURSING COMMUNICATION 8	Interval: --	Occurrences: --	Comments:	If a grade 1 or 2 infusion related reaction occurs, patients may be administered premedication prior to future Nivolumab infusions with diphenhydramine 50 mg and acetaminophen 325 to 1000 mg administered. The Nivolumab should start at least 30 minutes after the start of second premedication.
		  	ONC NURSING COMMUNICATION 9	Interval: --	Occurrences: --	Comments:	All the subsequent cycles for 1 year since first dose of Nivolumab will be similar as Cycle 2.
			Chemotherapy
  	INV-Nivolumab (EA5142/Pro00016419/Bernicker) 10 mg/mL 480 mg in sodium chloride 0.9% 100 mL (4.8 mg/mL) infusion	Dose: 480 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S	End: S		Instructions:	Prepared dose contains open label active Nivolumab. Administer intravenously via pump, using 0.2 to 1.2 micron inline filter, over 30 minutes. Stability of prepared dose: Room temperature, including infusion time: 4 hours. Refrigerated: 20 hours.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-NIVOLUMAB VIAL (EA5142/PRO00016419/BERNICKER)	Medications	480 mg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	52 mL	Yes	Yes				Discharge Nursing Orders
  	ONC NURSING COMMUNICATION 76	Interval: --	Occurrences: --	Comments:	Discontinue IV.
			Discharge Nursing Orders
☑	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN					☑	HEParin, porcine (PF) injection 500 Units	Dose: 500 Units	Route: intra-catheter	once PRN	Start: S			Instructions:	Concentration: 100 units/mL. Heparin flush for Implanted Vascular Access Device maintenance.					
Cycle 12	Repeat 1 time	Cycle length: 28 days	Day 1 (Infusion day)	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Line Care
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Nursing Orders
  	VITAL SIGNS - T/P/R/BP	Interval: --	Occurrences: --	Comments:	Pre-dose:  Blood pressure, body temperature, heart rate
		  	RESEARCH - MEASURE WEIGHT	Interval: --	Occurrences: --	Comments:	Pre-dose
		  	ONC NURSING COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	ECOG performance status
			Labs
  	HCG QUALITATIVE, SERUM SCREEN	Interval: --	Occurrences: --	Comments:	Only for women of childbearing potential
		  	HCG QUANTITATIVE, SERUM	Interval: --	Occurrences: --	Comments:	Only for women of childbearing potential
		  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		  	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		  	THYROID STIMULATING HORMONE	Interval: --	Occurrences: --		  	T3, FREE	Interval: --	Occurrences: --	Comments:	Only If TSH is abnormal
		  	T4, FREE	Interval: --	Occurrences: --	Comments:	Only If TSH is abnormal
			Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: --	Occurrences: --	Comments:	Grade 1 - MILD Symptoms (cutaneous and subcutaneous symptoms only - itching, flushing, periorbital edema, rash, or runny nose)
1. Stop the infusion.
2. Place the patient on continuous monitoring.
3. Obtain vital signs.
4. Administer Normal Saline at 50 mL per hour using a new bag and new intravenous tubing.
5. If greater than or equal to 30 minutes since the last dose of Diphenhydramine, administer Diphenhydramine 25 mg intravenous once.
6. If less than 30 minutes since the last dose of Diphenhydramine, administer Cetirizine 10 mg orally and Famotidine 20 mg intravenous once.
7. Notify the treating physician.
8. If no improvement after 15 minutes, advance level of care to Grade 2 (Moderate) or Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 4	Interval: --	Occurrences: --	Comments:	Grade 2 - MODERATE Symptoms (cardiovascular, respiratory, or gastrointestinal symptoms - shortness of breath, wheezing, nausea, vomiting, dizziness, diaphoresis, throat or chest tightness, abdominal or back pain)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
6. Administer Normal Saline at 150 mL per hour using a new bag and new intravenous tubing.
7. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous), Cetirizine 10 mg orally and Famotidine 20 mg intravenous once.
8. If no improvement after 15 minutes, advance level of care to Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 83	Interval: --	Occurrences: --	Comments:	Grade 3 – SEVERE Symptoms (hypoxia, hypotension, or neurologic compromise – cyanosis or O2 saturation less than 92%, hypotension with systolic blood pressure less than 90 mmHg, confusion, collapse, loss of consciousness, or incontinence)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. If heart rate is less than 50 or greater than 120, or blood pressure is less than 90/50 mmHg, place patient in reclined or flattened position.
6. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
7. Administer Normal Saline at 1000 mL intravenous bolus using a new bag and new intravenous tubing.
8. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous) and Famotidine 20 mg intravenous once.
9. Administer Epinephrine (1:1000) 0.3 mg subcutaneous.
10. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	PRN	Start: S				  	cetirizine (ZyrTEC) tablet 10 mg	Dose: 10 mg	Route: oral	once PRN	Start: S				  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	PRN	Start: S				  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	PRN					  	dexAMETHasone (DECADRON) IV 4 mg	Dose: 4 mg	Route: intravenous	PRN					  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					Pre-Medications
  	diphenhydrAMINE (BENADRYL) injection 50 mg	Dose: 50 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer if a grade 1 or 2 infusion related reaction occurs.		  	acetaminophen (TYLENOL) tablet 325 mg	Dose: 325 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer if a grade 1 or 2 infusion related reaction occurs.		  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer if a grade 1 or 2 infusion related reaction occurs.		  	acetaminophen (TYLENOL) tablet 975 mg	Dose: 975 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer if a grade 1 or 2 infusion related reaction occurs.			Chemotherapy
  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	Nivolumab is administered at a flat dose. The dose is 480 mg (administered every 4 weeks +/- 2 days) for up to 1 year total. Nivolumab is to be administered as a 30-minute (+/-5 minutes) IV infusion. The drug can be infused undiluted or diluted with 0.9% normal saline or 5% dextrose for delivery but the total drug concentration of the solution should be between 2mg/mL - 10mg/mL. It is not to be administered as an IV push or bolus injection. At the end of the infusion, flush the line with a sufficient quantity of normal saline. The total infusion volume should not exceed 120 mL.
		  	ONC NURSING COMMUNICATION 8	Interval: --	Occurrences: --	Comments:	If a grade 1 or 2 infusion related reaction occurs, patients may be administered premedication prior to future Nivolumab infusions with diphenhydramine 50 mg and acetaminophen 325 to 1000 mg administered. The Nivolumab should start at least 30 minutes after the start of second premedication.
		  	ONC NURSING COMMUNICATION 9	Interval: --	Occurrences: --	Comments:	All the subsequent cycles for 1 year since first dose of Nivolumab will be similar as Cycle 2.
			Chemotherapy
  	INV-Nivolumab (EA5142/Pro00016419/Bernicker) 10 mg/mL 480 mg in sodium chloride 0.9% 100 mL (4.8 mg/mL) infusion	Dose: 480 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S	End: S		Instructions:	Prepared dose contains open label active Nivolumab. Administer intravenously via pump, using 0.2 to 1.2 micron inline filter, over 30 minutes. Stability of prepared dose: Room temperature, including infusion time: 4 hours. Refrigerated: 20 hours.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-NIVOLUMAB VIAL (EA5142/PRO00016419/BERNICKER)	Medications	480 mg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	52 mL	Yes	Yes				Discharge Nursing Orders
  	ONC NURSING COMMUNICATION 76	Interval: --	Occurrences: --	Comments:	Discontinue IV.
			Discharge Nursing Orders
☑	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN					☑	HEParin, porcine (PF) injection 500 Units	Dose: 500 Units	Route: intra-catheter	once PRN	Start: S			Instructions:	Concentration: 100 units/mL. Heparin flush for Implanted Vascular Access Device maintenance.					
Cycle 13	Repeat 1 time	Cycle length: 42 days	Day 1 (Infusion day)	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Line Care
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Nursing Orders
  	VITAL SIGNS - T/P/R/BP	Interval: --	Occurrences: --	Comments:	Pre-dose:  Blood pressure, body temperature, heart rate
		  	RESEARCH - MEASURE WEIGHT	Interval: --	Occurrences: --	Comments:	Pre-dose
		  	ONC NURSING COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	ECOG performance status
			Imaging
  	CT CHEST W WO CONTRAST	Interval: --	Occurrences: --	Comments:	Including adrenals (within 1 month of randomization and every 6 months)
			Labs
  	HCG QUALITATIVE, SERUM SCREEN	Interval: --	Occurrences: --	Comments:	Only for women of childbearing potential
		  	HCG QUANTITATIVE, SERUM	Interval: --	Occurrences: --	Comments:	Only for women of childbearing potential
		  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		  	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		  	THYROID STIMULATING HORMONE	Interval: --	Occurrences: --		  	T3, FREE	Interval: --	Occurrences: --	Comments:	Only If TSH is abnormal
		  	T4, FREE	Interval: --	Occurrences: --	Comments:	Only If TSH is abnormal
			Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: --	Occurrences: --	Comments:	Grade 1 - MILD Symptoms (cutaneous and subcutaneous symptoms only - itching, flushing, periorbital edema, rash, or runny nose)
1. Stop the infusion.
2. Place the patient on continuous monitoring.
3. Obtain vital signs.
4. Administer Normal Saline at 50 mL per hour using a new bag and new intravenous tubing.
5. If greater than or equal to 30 minutes since the last dose of Diphenhydramine, administer Diphenhydramine 25 mg intravenous once.
6. If less than 30 minutes since the last dose of Diphenhydramine, administer Cetirizine 10 mg orally and Famotidine 20 mg intravenous once.
7. Notify the treating physician.
8. If no improvement after 15 minutes, advance level of care to Grade 2 (Moderate) or Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 4	Interval: --	Occurrences: --	Comments:	Grade 2 - MODERATE Symptoms (cardiovascular, respiratory, or gastrointestinal symptoms - shortness of breath, wheezing, nausea, vomiting, dizziness, diaphoresis, throat or chest tightness, abdominal or back pain)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
6. Administer Normal Saline at 150 mL per hour using a new bag and new intravenous tubing.
7. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous), Cetirizine 10 mg orally and Famotidine 20 mg intravenous once.
8. If no improvement after 15 minutes, advance level of care to Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 83	Interval: --	Occurrences: --	Comments:	Grade 3 – SEVERE Symptoms (hypoxia, hypotension, or neurologic compromise – cyanosis or O2 saturation less than 92%, hypotension with systolic blood pressure less than 90 mmHg, confusion, collapse, loss of consciousness, or incontinence)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. If heart rate is less than 50 or greater than 120, or blood pressure is less than 90/50 mmHg, place patient in reclined or flattened position.
6. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
7. Administer Normal Saline at 1000 mL intravenous bolus using a new bag and new intravenous tubing.
8. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous) and Famotidine 20 mg intravenous once.
9. Administer Epinephrine (1:1000) 0.3 mg subcutaneous.
10. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	PRN	Start: S				  	cetirizine (ZyrTEC) tablet 10 mg	Dose: 10 mg	Route: oral	once PRN	Start: S				  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	PRN	Start: S				  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	PRN					  	dexAMETHasone (DECADRON) IV 4 mg	Dose: 4 mg	Route: intravenous	PRN					  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					Pre-Medications
  	diphenhydrAMINE (BENADRYL) injection 50 mg	Dose: 50 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer if a grade 1 or 2 infusion related reaction occurs.		  	acetaminophen (TYLENOL) tablet 325 mg	Dose: 325 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer if a grade 1 or 2 infusion related reaction occurs.		  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer if a grade 1 or 2 infusion related reaction occurs.		  	acetaminophen (TYLENOL) tablet 975 mg	Dose: 975 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer if a grade 1 or 2 infusion related reaction occurs.			Chemotherapy
  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	Nivolumab is administered at a flat dose. The dose is 480 mg (administered every 4 weeks +/- 2 days) for up to 1 year total. Nivolumab is to be administered as a 30-minute (+/-5 minutes) IV infusion. The drug can be infused undiluted or diluted with 0.9% normal saline or 5% dextrose for delivery but the total drug concentration of the solution should be between 2mg/mL - 10mg/mL. It is not to be administered as an IV push or bolus injection. At the end of the infusion, flush the line with a sufficient quantity of normal saline. The total infusion volume should not exceed 120 mL.
		  	ONC NURSING COMMUNICATION 8	Interval: --	Occurrences: --	Comments:	If a grade 1 or 2 infusion related reaction occurs, patients may be administered premedication prior to future Nivolumab infusions with diphenhydramine 50 mg and acetaminophen 325 to 1000 mg administered. The Nivolumab should start at least 30 minutes after the start of second premedication.
		  	ONC NURSING COMMUNICATION 9	Interval: --	Occurrences: --	Comments:	All the subsequent cycles for 1 year since first dose of Nivolumab will be similar as Cycle 2.
			Chemotherapy
  	INV-Nivolumab (EA5142/Pro00016419/Bernicker) 10 mg/mL 480 mg in sodium chloride 0.9% 100 mL (4.8 mg/mL) infusion	Dose: 480 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S	End: S		Instructions:	Prepared dose contains open label active Nivolumab. Administer intravenously via pump, using 0.2 to 1.2 micron inline filter, over 30 minutes. Stability of prepared dose: Room temperature, including infusion time: 4 hours. Refrigerated: 20 hours.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-NIVOLUMAB VIAL (EA5142/PRO00016419/BERNICKER)	Medications	480 mg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	52 mL	Yes	Yes				Discharge Nursing Orders
  	ONC NURSING COMMUNICATION 76	Interval: --	Occurrences: --	Comments:	Discontinue IV.
			Discharge Nursing Orders
☑	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN					☑	HEParin, porcine (PF) injection 500 Units	Dose: 500 Units	Route: intra-catheter	once PRN	Start: S			Instructions:	Concentration: 100 units/mL. Heparin flush for Implanted Vascular Access Device maintenance.					
Post Treatment Follow-Up	Repeat 1 time	Cycle length: 1 day	Follow-Up 1 (6 weeks +/- 2 days after last dose of Nivolumab)	Perform every 1 day x1		Nursing Orders
  	VITAL SIGNS - T/P/R/BP	Interval: --	Occurrences: --	Comments:	Blood pressure, body temperature, heart rate
		  	RESEARCH - MEASURE WEIGHT	Interval: --	Occurrences: --		  	ONC NURSING COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	ECOG performance status
			Labs
  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		  	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		  	THYROID STIMULATING HORMONE	Interval: --	Occurrences: --		  	T3, FREE	Interval: --	Occurrences: --	Comments:	Only If TSH is abnormal
		  	T4, FREE	Interval: --	Occurrences: --	Comments:	Only If TSH is abnormal
		  	RESEARCH STUDY SPECIMEN	Interval: --	Occurrences: --			Imaging
  	CT CHEST W WO CONTRAST	Interval: --	Occurrences: --	Comments:	Including adrenals