The confused oncologic patient: a rational clinical approach

Mishel's uncertainty in illness theory: Informing nursing diagnoses and care planning

PURPOSE

Patients with glioblastoma multiforme (GBM) face uncertainty during the illness trajectory that decreases their quality of life. Uncertainty manifests as an altered state of mind in patients with GBM and increases the burden of managing their diagnosis. The uncertainty in illness theory (UIT) can be used to guide nursing practice and create care plans to decrease this uncertainty.

DATA SOURCES

The UIT and conceptual model were used to pair diagnoses from NANDA-I Nursing Diagnoses to form care plans for patients with GBM.

METHODS

In a stepwise approach, concepts from the UIT were organized and cross-walked into an integrated theory-driven practice framework to enhance care planning.

CONCLUSIONS

The UIT helps define and identify circumstances of uncertainty in patients experiencing illness, and Nursing Diagnoses provide engagement and outcomes for those uncertainty-based diagnoses. Some examples of the UIT guiding Nursing Diagnoses includes a patient's cognitive level guiding a Nursing Diagnosis care plan of Risk for Acute Confusion. Social Support can guide the care plan of Risk for Loneliness, and appraisal of uncertainty can guide a care plan for Ineffective Individual Coping. Using the UIT to guide theory-driven practice links interventions and outcomes in patients with GBM.

IMPLICATIONS FOR PRACTICE

The UIT can guide NANDA-I Nursing Diagnoses to assist nurses in creating a nursing care plan for nursing engagement to decrease uncertainty and increase the quality of life in patients with GBM. Theory-driven research defines the application of the UIT in GBM and provides foundational knowledge for theory-driven practice to occur.

A 47-Year-Old Woman with Confusion and Weakness

A 47-Year-Old Woman with Confusion and WeaknessA 47-year-old woman with metastatic breast cancer presents with 3 months of confusion, memory loss, and lower-extremity weakness. How do you approach the evaluation, and what is the differential diagnosis?

Accuracy of Delirium Screening Tools in Older People with Cancer-A Systematic Review

BACKGROUND

The increase in life expectancy worldwide has led to a larger population of older people, which in turn entails a rising prevalence of cancer. One of the main complications of cancer is delirium, especially in advanced stages.

OBJECTIVE

To determine which delirium screening instrument is the most accurate in older people with cancer.

METHODS

A systematic review was designed. A literature search was performed in MEDLINE, EBSCO and SCOPUS; additional records were identified by handsearching. Selection criteria were studies involving people with cancer and a mean sample age of 60 years or older, assessing delirium, and reporting the metric properties of the assessment instrument. Studies with post-surgical patients and substance abuse delirium were excluded.

RESULTS

From 2001 to 2021, 14 eligible studies evaluated 13 different assessment tools, reporting an incidence of delirium ranging from 14.3% to 68.3%. The Delirium Observation Screening Scale (DOSS) showed the best metric properties, followed by the Nursing Delirium Screening Scale (NuDESC), Confusion Assessment Method (CAM) and Memorial Delirium Assessment Scale (MDAS). Only two studies were considered to be at low risk of bias using the QUADAS-2 Tool. No study exclusively examined this population group.

CONCLUSIONS

Screening tools for delirium are heterogeneous for older people with cancer, and there is a need to analyze metric properties exclusively in the older population. Registered on PROSPERO ID: CRD42022303530.

Neurologic Complications in Patients With Cancer

PURPOSE OF REVIEW

Neurologic complications in patients with cancer can significantly impact morbidity and mortality. Although these complications can be seen in patients without cancer as well, the purpose of this review is to highlight how the presentation, etiology, and management of delirium, seizures, cerebrovascular disease, and central nervous system infections may be different in patients with cancer.

RECENT FINDINGS

Some of the newer anticancer therapies are associated with neurologic complications. Delirium and seizures have been described in patients receiving chimeric antigen receptor (CAR) T-cell therapy and other immune effector cell therapies. Angiogenesis inhibitors can increase the risk of bleeding and clotting, including intracranial hemorrhage and stroke. The risk of opportunistic fungal infections, including aspergillosis, is elevated with the Bruton tyrosine kinase inhibitor ibrutinib.

SUMMARY

Providers should familiarize themselves with neurologic complications in patients with cancer because early diagnosis and intervention can improve outcomes. The differential diagnosis should be broad, including conventional causes as seen in patients who do not have cancer, with special consideration of etiologies specific to patients with cancer.

A 5-Fluorouracil-Induced Hyperammonemic Encephalopathy Challenged with Capecitabine

Cancer patients presenting with altered mental status demand a broad differential with early recognition of the etiology. Failure to do so is associated with increased morbidity and mortality. Causes that must be considered include organ involvement of the cancer, electrolytes abnormalities, and even chemotherapeutic agents. A 32-year-old female patient had been recently started on FOLFOX for metastatic colon cancer. Her initial treatments were uneventful, but she later developed encephalopathy during day three of cycle five. During her evaluation, she was found to have hyperammonemia (84 mcmol/L), without hepatic failure, that resolved with stopping chemotherapy and supportive care. After a trial of home infusion fluorouracil, she developed hyperammonemic encephalopathy again. During both admissions, her symptoms resolved with IV hydration and cessation of chemotherapy. She was then successfully challenged with capecitabine (1000 mg/m² daily), and additional hydration, and continued chemotherapy without recurrence of symptoms. Hyperammonemia is associated with fluorouracil though the mechanism is unclear. Suspected etiologies include either elevated levels of the drug due to slower metabolism or accumulation of certain metabolites. Additionally, risk factors such urease-producing bacterial infections, dehydration, and increased catabolism are thought to increase the risk for hyperammonemia. This case demonstrates the need for greater awareness of fluorouracil as a cause of hyperammonemic encephalopathy. Knowledge of this may allow for earlier recognition and reduced unnecessary testing.