Symptom: Swelling/Puffiness (Edema)

Initial Grading Reminder

CTCAE grading of edema:

Grade 1 (Mild): Swelling or obscuration of anatomic architecture on close inspection
Grade 2 (Moderate): Readily apparent obscuration of anatomic architecture; obliteration of skin folds; limiting instrumental ADLs
Grade 3 (Severe): Gross deviation from normal anatomic contour; limiting self-care ADLs

Assessment and Grading

Characterize the symptom (onset, pace)

Ask the patient:

Have you had issues with swelling 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 bad is the swelling? Can you see your ankles, etc? Is the skin tense? Are you able to carry out your normal activities?

Patient Query Regarding Other Symptoms/Red Flags

Ask the patient:

Are you having any changes in urination? Are you swollen elsewhere? Do you have any nausea, vomiting? Are you confused? Is it difficult to breathe? Are you very fatigued? Do you have any chest pain? Does your heart feel like it is racing or skipping a beat?

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

    If the patient has new-onset moderate or worse (or worsening) edema should be seen.

    If any of the red-flag symptoms are present, the patient should be seen immediately.

    Patients with severe shortness of breath or any chest pain should go to the ED.

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    Nursing Assessment of Potential Causes

    Nephritis - Nursing Assessment

    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • 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

    • 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 swelling?