Symptom: Sores in Rectum

Initial Grading Reminder

CTCAE grading of rectum sores:

Grade 1: Asymptomatic or mild symptoms; intervention not indicated
Grade 2: Symptomatic; medical intervention indicated; limiting instrumental ADLs
Grade 3: Severe symptoms; limiting self-care ADLs
Grade 4: Life-threatening consequences; urgent operative intervention indicated

Assessment and Grading

Characterize the symptom (onset, pace)

Ask the patient:

Have you had any issues with rectal sores in the past? Is this a new or worsening symptom? When did it start or get worse? Has it developed gradually or suddenly?

Grade the symptom

Ask the patient:

How much pain are you experiencing in your rectum? Is it affecting your ability to have bowel movements?

Patient Query Regarding Other Symptoms/Red Flags

Ask the patient:

Do you also have sores on your skin? How much of your body is affected? Do you have blisters? Are the sores limiting your ability to take care of yourself?  Do you also have any ulcers/blisters in your mouth?

Do you have diarrhea? Do you any abdominal (belly) pain/tenderness, nausea, fever, or decreased appetite? Blood in the stool?

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) rectal sores 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)

    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)

    Differential Diagnosis

    What do you suspect is the cause of the sores in the rectum?