Symptom: Abdominal Bloating

  • Initial Grading Reminder

    CTCAE grading of abdominal bloating:

    • Grade 1: Mild symptoms; intervention not indicated
    • Grade 2: Moderate symptoms; medical intervention indicated
    • Grade 3: Severe symptoms; surgical intervention indicated
  • Assessment and Grading

    Characterize the symptom (onset, pace)

    Ask the patient:

    “Have you had any issues with bloating in your abdomen (belly) in the past? Any Crohn’s disease or cancer metastases to your bowel? Is this a new or worsening symptom? When did it start or get worse? Has it developed gradually or suddenly? Has your diet changed in the past day? What have done/taken to treat it thus far? Do you drink a lot of carbonated beverages? Are you passing gas?”

    Suddenly would be more consistent with peritoneal signs.

    Grade the symptom

    Ask the patient:

    “How would you rate your abdominal (belly) bloating (mild, moderate, or severe)? Is it affecting your ability to function?”

  • Patient Query Regarding Other Symptoms/Red Flags

    Ask the patient:

    “Do you have any changes in your bowel movements? Any abdominal pain/tenderness, nausea, fever, or change in appetite?

    Do you have any yellowing of the skin or whites of your eyes, abdominal (belly) pain, sleepiness, or is your thinking foggy?

    Do you have new or worsening shortness of breath, increased fatigue or chest pain? Does your heart feel like it is racing or skipping a beat?”

  • Patient Factors to Consider That Affect the Approach to Intervention

    Consider the following in individualizing the intervention: Is the patient a good or poor historian? Any language barriers or cognitive deficits? Is the patient reliable (able to carry out treatment recommendations)? Does this patient have alcohol/substance abuse issues? Does the patient have transportation? Is there sufficient caregiver support?

Telephone Triage: Suggested Intervention

If  the abdominal bloating is moderate or worse (or worsening), the patient should be seen.

If any of the red-flag symptoms are present, the patient should be seen immediately. Patients with severe shortness of breath or any chest pain should go to the ED.

In-Office Triage: Nursing Assessment of Potential Causes

GI Toxicity - Nursing Assessment

  • Look
  • Listen
  • Recognize
  • Look
  • Listen
  • Recognize
  • Look
  • Listen
  • Recognize
  • Does the patient appear weak?
  • Has the patient lost weight?
  • Does the patient appear dehydrated?
  • Does the patient appear in distress?
  • Quantity & quality of bowel movements (e.g., change in/increased frequency over baseline): solid, soft, or liquid diarrhea; dark or bloody stools; or stools that float
  • Fever
  • Abdominal pain or cramping
  • Increased fatigue
  • Upset stomach, nausea, or vomiting
  • Bloating/increased gas
  • Decreased appetite or food aversions
  • Serum chemistry/hematology abnormalities
  • Infectious vs immune-related adverse event causation
  • Peritoneal signs of bowel perforation (i.e., pain, tenderness, bloating)

Cardiotoxicity - Nursing Assessment

  • Look
  • Listen
  • Recognize
  • Look
  • Listen
  • Recognize
  • Look
  • Listen
  • Recognize
  • Does the patient look unwell?
  • Fatigued?
  • Diaphoretic?
  • SOB or in respiratory distress?
  • Is there leg edema?
  • Change in energy level?
  • SOB or DOE?
  • Leg edema?
  • Palpitations?
  • Changes in BP?
  • Dizziness or syncope?
  • What exacerbates or improves symptoms?
  • Any new prescribed or OTC meds? Illicit substances?
  • Any underlying cardiac disease (CAD, MI, or other)?
  • What exacerbates or improves symptoms?
  • Prior radiation therapy?
  • Determine specific toxicity and related grade (if applicable)
  • Other related symptoms: hypotension, syncope, chest pain, DOE, SOB, palpitations, edema, etc.
  • Impact of symptoms on QOL/performance status
  • Changes in cardiac function: ECG changes, decreased EF, elevated cardiac enzymes (troponin, CK)
  • Assess other changes in oxygen saturation, BP, lung function

Differential Diagnosis

What do you suspect is the cause of abdominal bloating?