GI Toxicity - Nursing Assessment

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  • 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)

Skin Toxicities - Nursing Assessment

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  • 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)

Mucositis & Xerostomia - Nursing Assessment

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  • Does the patient appear uncomfortable?
  • Does the patient appear unwell?
  • Difficulty talking?
  • Licking lips to moisten often?
  • Weight loss?
  • Does the patient appear dehydrated?
  • Does the patient have thrush?
  • Does the patient report?
    • Mouth pain (tongue, gums, buccal mucosa)
    • Mouth sores
    • Difficulty eating
    • Waking during the sleep to sip water
    • Recent dental-related issues
    • Need for dental work (e.g., root canal, tooth extraction)
  • Have symptoms worsened?
  • A history of mouth sores
  • Does patient smoke?
  • Concomitant medications associated with causing dry mouth?
  • Reports of dry mouth often accompany mucositis
  • Other reports of dry membranes (e.g., eyes, nasal passages, vagina)

Hepatotoxicity - Nursing Assessment

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  • 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)

Hypophysitis - Nursing Assessment

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  • Does the patient appear fatigued?
  • Does the patient look listless?
  • Does the patient look ill?
  • Does the patient look uncomfortable?
  • Does the patient report:
    • Change in energy?
    • Headache?
    • Dizziness?
    • Nausea/vomiting?
    • Altered mental status?
    • Visual disturbances?
    • Fever?
  • Low levels of hormones produced by pituitary gland (ACTH, TSH, FSH, LH, GH, prolactin)
  • Brain MRI with pituitary cuts: enhancement and swelling of the pituitary gland
  • DDX adrenal insufficiency: low cortisol and high ACTH
  • DDX primary hypothyroidism: low free T4 and high TSH

Thyroiditis - Nursing Assessment

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  • Does the patient appear unwell?
  • Changes in weight since last visit
    • Appear heavier? Thinner?
  • Changes in hair texture/thickness?
  • Appearing hot/cold?
  • Does the patient look fatigued?
  • Appetite/weight changes?
  • Hot or cold intolerance?
  • Change in energy, mood, or behavior?
  • Palpitations?
  • Increased fatigue?
  • Bowel-related changes?
    • Constipation/diarrhea
  • Skin-related changes?
    • Dry/oily
  • Ensure that patient undergoes thyroid function tests prior to first dose, every 12 weeks while on PD-1 therapy and q3 weeks with ipilimumab
  • High TSH with low free T4 consistent with primary hypothyroidism
  • DDX: secondary hypothyroidism due to hypophysitis, low TSH and low free T4
  • Occasionally thyroiditis with transient hyperthyroidism (low TSH and high free T4) may be followed by more longstanding hypothyroidism (high TSH and low free T4)
  • Other immune-related toxicity?
  • Prior thyroid dysfunction?

Type 1 Diabetes Mellitus - Nursing Assessment

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  • Does the patient appear fatigued?
  • Does the patient appear dehydrated?
  • Does the breath have a sweet/fruity smell?
  • Is the patient tachycardic?
  • Frequent urination?
  • Increased thirst?
  • Increased hunger?
  • Increased fatigue?
  • Altered level of consciousness with advanced cases
  • Symptoms of diabetes
  • Serum glucose levels
  • Other immune-related toxicity
  • Infections

Pneumonitis - Nursing Assessment

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  • 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?

Arthralgias and Arthritis - Nursing Assessment

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  • 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

Neuropathy - Nursing Assessment

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  • 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

Nephritis - Nursing Assessment

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  • Does the patient appear uncomfortable?
  • Does the patient look ill?
  • Has there been change in urination?
    • Urine color?
    • Frequency?
  • How much fluid is the patient taking in?
  • Are associated symptoms present?
    • Nausea?
    • Headache?
    • Malaise?
    • Lung edema?
  • Are there symptoms indicative of:
    • Urinary tract infection?
    • Pyelonephritis?
    • Worsening CHF?
  • Are symptoms limiting ADLs?
  • Current or recent use of nephrotoxic medications (prescribed and OTC), other agents?
    • NSAIDs
    • Antibiotics
    • Contrast media or other nephrotoxic agents (contrast dye, aminoglycosides, PPI)?
  • Laboratory abnormalities (elevated creatinine, electrolyte abnormalities)
  • Urinalysis abnormalities (casts)
  • Abdominal or pelvic disease that could be causing symptoms
  • Prior history of renal compromise?
  • Other immune-related adverse effects?
  • Presence of current or prior immune-mediated toxicities, including rhabdomyolysis
  • Is patient volume depleted?

Cardiotoxicity - Nursing Assessment

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  • 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

Encephalopathy - Nursing Assessment

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  • Does the patient look uncomfortable?
  • Does the patient look ill?
  • Does the patient report headache, fever, tiredness, sleepiness, hallucinations, stiff neck?
  • Signs of infectious cause (lumbar puncture); Obtain brain MRI; Consult neurologist