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Cytarabine Neurological Flowsheet (4006195-DT)

Cytarabine Neurological Flowsheet (4006195-DT) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Questionnaires


 
Patient Name 

DOB:

MR #
 
Index to Flow Sheet \ Encounter 

UWH# 4006195-DT (Rev. 07/11/16) CYTARABINE NEUROLOGICAL MONITORING FLOWSHEET
Page 1 of 2
 
UW Health uwhealth.org
(University of Wisconsin Hospitals and Clinics Authority)
CYTARABINE NEUROLOGICAL MONITORING
FLOW SHEET 
(Assessment Required per Treatment Plan Orders)
Initials Signature Initials Signature




Date & Time


(Baseline)
Cycle/Dose
RN initials
Level of Consciousness
0=alert or easily aroused
1=confused or somnolent

Speech Pattern
0= clear
1= slurred or confused

Nystagmus
0= no beats present
1= rhythmic beats present

Gait
1

0= steady
1= unsteady, loses balance

Romberg Test
2
0= steady
1= unsteady, loses balance

Tremors of Arms
3
0= no tremors
1= tremors present

Upper Extremity Coordination
Rapid Alternating Movements (RAMs)
4
0= smoothly
1= clumsy, awkward

Point-to-Point Testing
5
0= smoothly
1= clumsy, awkward

Lower Extremity Coordination
RAMs
6
0= smoothly
1= clumsy, awkward

Point-to-Point Testing
7
0= smoothly
1= clumsy, awkward

Total (if > 1 withhold drug, notify physician)











 
Patient Name 

DOB:

MR #
 
Index to Flow Sheet \ Encounter 

UWH# 4006195-DT (Rev. 07/11/16) CYTARABINE NEUROLOGICAL MONITORING FLOWSHEET
Page 2 of 2
 
UW Health uwhealth.org
(University of Wisconsin Hospitals and Clinics Authority)
CYTARABINE NEUROLOGICAL MONITORING
FLOW SHEET 
PATIENT SIGNATURE PAGE
(For assessment purpose only)
Signatures

1. (Baseline)_______________________________________________Date:___________ Time:________

2. _______________________________________________________Date:___________ Time:________

3. _______________________________________________________Date:___________ Time:________

4. _______________________________________________________Date:___________ Time:________

5. _______________________________________________________Date:___________ Time:________

6. _______________________________________________________Date:___________ Time:________

7. _______________________________________________________Date:___________ Time:________


Date & Time

(Baseline)
Cycle/Dose
RN initials
Skin/Mucus Membranes
0= no lesions or complaints
1= rash/erythema or patient with complaints

Ocular
0= no lesions or complaints
1= irritation/lesions or patient with complaints

Patient Signature
0= unchanged from baseline signature
1= deviation from baseline signature or unable to
complete signature

Total (if > 1 withhold drug, notify physician)



Assessment Guidance
1
Have the patient walk heel-to-toe in a straight line.
2
Ask the patient to stand with feet together. Note ability to maintain upright posture, first with eyes open and then with eyes closed for 20-
30 seconds
3
While sitting on the side of the bed, ask the patient to hold arms straight forward with palms up.
4
While sitting, have the patient place their palm to their thigh, then place their back hand to the thigh and repeat this as quickly as possible
back and forth.
5
While sitting, have the patient touch your index finger and then his/her nose, move your finger and repeat several times.
6
While supine, have the patient tap your hand with the ball of his/her foot, alternating feet as quickly as possible.
7
While supine, ask the patient to place one heel on the opposite knee and then run it down the shin to the great toe.
(Revised 12/12/2015)
Document is based on Neurotoxicity Assessment Tool used at Yale-New Haven Hospital as referenced in:
Lundquist, D. & Holmes, W. (1993). Documentation of neurotoxicity resulting from high-dose cytosine arabinoside. Oncology Nursing Forum, 20(9), 1409
1413.