High Dose Cytarabine Neurological Assessment Guide Streamlines Symptom Documentation

WASHINGTON, DC—A Nursing Journal Club presentation about assessing and documenting use of high dose cytarabine (≥1g/m2) prompted the University of Maryland Marlene and Stewart Greenebaum Cancer Center Clinical Practice Council to review their “neuro check” practices, according to a presentation at the Oncology Nursing Society (ONS) 38th Annual Congress.

Patients who receive high dose cytarabine have a 7% to 28% incidence of neurotoxicity, explained Barbara Bigelow, RN, BSN, OCN®, of the Cancer Center in Baltimore, MD. However, “inexplicit and inconsistent orders for ‘neuro checks before high dose cytarabine' meant assessment and documentation practices varied among nurses and physicians.”

Bedside nurses play a critical role in recognizing neurological symptoms, and timely intervention can reduce the severity of and potential for long-term complications. The Council's goal was to create a standardized neurologic assessment that enabled nurses to identify, treat promptly, and efficiently document adverse neurologic effects from high dose cytarabine infusions.

A literature review identified essential components of a neurologic assessment pertinent to high dose cytarabine that led to development of a two-sided “High Dose Cytarabine Neurological Assessment” guide and documentation form. “The guide identifies risk factors associated with neurotoxicity and use of high dose cytarabine,” Bigelow noted. Directions are also provided on how to perform assessments of cerebral status (level of sedation, mentation, cognitive status, presence of headache, and seizure activity) and cerebellar function (gaze, speech pattern, handwriting, arm tremor, upper and lower extremity coordination, gait, and balance).

On the reverse side of the form, nurses document adverse assessment findings, facilitating “prompt recognition of neurotoxicity. The form instructs the nurse to stop the infusion for abnormal findings and to contact the prescriber,” she stated. Nurses use the form before administering sedatives and each cytarabine infusion.

A pre-implementation neurologic assessment/documentation practices survey was sent to 66 registered nurses; response rate was 50%. Participants were instructed to rate their responses to the questions on a 10 Likert 5 point scale. All respondents reported administering high-dose cytarabine; half of these said they had done so in the previous month.

The overwhelming majority of nurses reported that they knew what assessments to perform; that assessments were easy to perform and feasible in the clinical setting; that they were comfortable performing neurologic assessments; that they knew the adverse events associated with high-dose cytarabine infusions; and that they felt comfortable communicating a patient's neurologic changes.

Although most nurses knew what neurologic assessments to perform, there was anecdotal variation in practice. One in four nurses reported receiving inconsistent information about what neurologic assessment to perform. Looking at  current neurologic assessment  documentation, one in five nurses noted it was not easy and nearly one out of two nurses reported it is not comprehensive.

The Cancer Center plans to conduct a post-implementation survey.

“A standardized neurologic assessment guide and form has the potential for facilitating high-dose cytarabine neurological assessments and documentation,” the researchers concluded.

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