Symptom: Hands, Difficulty Using

Initial Grading Reminder

CTCAE grading of difficulty using hands:

Grade 1: Asymptomatic; clinical or diagnostic observations only; intervention not indicated
Grade 2: Moderate symptoms; limiting instrumental ADLs
Grade 3: Severe symptoms; limiting self-care ADLs; mechanical assistance indicated

Assessment and Grading

Characterize the symptom (onset, pace)

Ask the patient:

Is this a new or worsening symptom? When did it start or get worse? Have you had any difficulty using your hands in the past? Has it developed gradually or suddenly?

Grade the symptom

Ask the patient:

How much difficulty do you have using your hands? Have you been dropping or having difficulty gripping objects? What tasks can you or can’t you do?

Patient Query Regarding Other Symptoms/Red Flags

Ask the patient:

Are you also having any difficulty breathing? Are you having trouble with any other joints in your body? If so, are you worried about falling?

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 new-onset moderate or worse (or worsening) symptoms should be seen.

    Patients with difficulty breathing or who are at a fall risk because of arthritis/arthralgia should be seen immediately.

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    Nursing Assessment of Potential Causes

    Neuropathy - Nursing Assessment

    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Does the patient appear weak?
    • Does the patient appear uncomfortable?
    • Altered ambulation or general movement?
    • If muscular weakness is present, any respiratory difficulties apparent?
    • Does the patient report weakness (unilateral or bilateral)?
    • Does the patient report new or worsened pain, numbness, or tingling?
    • Does the patient report difficulty walking or holding items?
    • Motor deficits
    • Sensory deficits
    • Mental status changes
    • Paresthesias
    • Laboratory values
    • Does the patient have diabetes mellitus?
    • Are there neurologic signs and symptoms?
    • Results of prior imaging
      • Metastases to spinal cord
      • Other metastases that may cause symptoms

    Arthralgias and Arthritis - Nursing Assessment

    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Does the patient appear uncomfortable?
    • Does the patient appear unwell?
    • Is gait affected?
    • Obvious swollen or deformed joint(s)?
    • Is the patient having trouble getting up and down stairs?
    • Have symptoms worsened?
    • Are symptoms limiting ADLs?
    • Are symptoms increasing the patient’s risk for fall? Other safety issues?
    • Associated symptoms?
      • Fatigue (new or worsening)
    • Is there a pre-existing autoimmune dysfunction?
    • Is there a history of prior orthopedic injury, DJD, OA, RA?
    • Other immune-related adverse effects
    • Three subtypes of inflammatory arthritis associated with checkpoint inhibitors:
      1. Polyarthritis similar to rheumatoid arthritis
      2. True reactive arthritis with conjunctivitis, urethritis, and oligoarthritis
      3. Subtype similar to seronegative spondyloarthritis with inflammatory back pain and predominantly larger joint involvement

    Differential Diagnosis

    What do you suspect is the cause of the patient’s flatulence?