Symptom: Itchiness

Initial Grading Reminder

CTCAE Criteria for Itchiness:

Grade 1 (Mild): Mild or localized; topical intervention indicated
Grade 2 (Moderate): Intense or widespread; intermittent; skin changes from scratching (e.g., edema, papulation, excoriations, lichenification, oozing/crusts); oral intervention indicated; limiting instrumental ADLs
Grade 3 (Severe): Intense or widespread; constant; limiting self-care ADLs or sleep; oral corticosteroid or immunosuppressive therapy indicated

Assessment and Grading

Characterize the symptom (onset, pace)

Ask the patient:

Have you had an issue with itchiness/dry skin in the past? Where on your body is it itchy? Do you have a rash or any tiny red bumps where it is itchy? If so, could you please send a photo? Are you taking any new medications, OTCs, supplements, or marijuana (especially antibiotics or anti-seizure medications)?

Grade the symptom

Ask the patient:

How itchy is your skin? Have you been scratching it? Is it interfering with your normal daily activities or sleep?

Patient Query Regarding Other Symptoms/Red Flags

Ask the patient:

Do you have a rash over more than 50% of your body? Is your mouth involved? Do any of the sores look infected? Do you have yellowing of the skin, abdominal (belly) pain, abdominal bloating, and/or nausea?

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) itchiness should be seen. Patients with any of the red-flag symptoms should be seen immediately.

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    Nursing Assessment of Potential Causes

    Skin Toxicities - Nursing Assessment

    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Does the patient appear uncomfortable?
    • Does the patient appear unwell?
    • Is there an obvious rash?
    • Is the patient scratching during the visit?
    • Is skin integrity intact?
    • Are there skin changes?
      • Xerosis
      • Changes in skin pigment or color
    • Is there oral involvement of the rash?
    • Does the patient have pruritus with or without rash? Is there a rash with or without pruritus?
    • Are symptoms interfering with ADLs?
    • With sleep?
    • Have symptoms worsened?
    • Is there a history of dermatitis, pre-existing skin issues (psoriasis, wounds, etc.)?
    • Laboratory abnormalities consistent with other etiologies (e.g., eosinophils on complete blood count, liver function abnormalities)

    Hepatotoxicity - Nursing Assessment

    • Look
    • Listen
    • Recognize
    • Look
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    • Recognize
    • Look
    • Listen
    • Recognize
    • Does the patient appear fatigued or listless?
    • Does the patient appear jaundiced?
    • Does the patient appear diaphoretic?
    • Does the patient have any ascites?
    • Change in energy level?
    • Change in skin color? Yellowing?
    • Change in stool color (paler)?
    • Change in urine color (darker/tea colored)?
    • Abdominal pain: specifically, right upper quadrant pain?
    • Bruising or bleeding more easily?
    • Fevers?
    • Change in mental status?
    • Increased sweating?
    • Elevation in LFTs
      • AST/SGOT
      • ALT/SGPT
      • Bilirubin (total/direct)
    • Alteration in GI function
    • Symptoms such as abdominal pain, ascites, somnolence, and jaundice
    • Other potential causes (viral, drug toxicity, disease progression)

    Differential Diagnosis

    What do you suspect is the cause of the itchiness?