Symptom: Cough

Initial Grading Reminder

CTCAE grading of cough:

Grade 1: Mild symptoms; nonprescription intervention indicated
Grade 2: Moderate symptoms, medical intervention indicated; limiting instrumental ADLs
Grade 3: Severe symptoms; limiting self-care ADLs

Assessment and Grading

Characterize the symptom (onset, pace)

Ask the patient:

Do you have any existing asthma or emphysema? Is this a new or worsening symptom? When did it start or get worse? Has it developed gradually or suddenly? Is it dry or productive? Any associated shortness of breath? Any sick contacts or other upper respiratory track symptoms such as fevers/chills, nasal congestion, or post-nasal drip? Are you smoking or using marijuana?

Grade the symptom

Ask the patient:

How often are you coughing? Is the cough interfering with your ability to take care of yourself?

Patient Query Regarding Other Symptoms/Red Flags

Ask the patient:

Are you able to get enough air to feel comfortable at rest? Do you have any chest pain? Does your heart feel like it is racing or skipping a beat? Do you have extreme fatigue along with swelling?

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?

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    Suggested Intervention

    Patients with moderate or worse (or worsening) cough should be seen.

    Patients with new-onset or severe shortness of breath or any other red-flag symptoms should be seen immediately.

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    Nursing Assessment of Potential Causes

    Pneumonitis - Nursing Assessment

    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Does the patient appear uncomfortable?
    • Did the patient have difficulty walking to the exam room? Or going up stairs?
    • Does the patient appear short of breath?
    • Is the patient tachypneic?
    • Does the patient appear to be in respiratory distress?
    • Has the patient noted any change in breathing?
    • Does the patient feel short of breath?
    • Does the patient note new dyspnea on exertion?
    • Does the patient notice a new cough? Or a change in an existing cough?
    • Have symptoms worsened?
    • Are symptoms limiting ADLs?
    • Associated symptoms?
      • Fatigue
      • Wheezing
    • Is the pulse oximetry low? Is it lower than baseline or compared with last visit? Is it low on exertion?
    • Is there a pre-existing pulmonary autoimmune condition (i.e., sarcoidosis)?
    • Is there a history of prior respiratory compromise (e.g., asthma, COPD, congestive heart failure)?
    • Has the patient experienced other immune-related adverse effects?

    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  the cough?