Symptom: Appetite, Loss of

Initial Grading Reminder

CTCAE grading of loss of appetite:

Grade 1 (Mild): Loss of appetite without alteration in eating habits
Grade 2 (Moderate): Oral intake decreased without significant weight loss, dehydration or malnutrition
Grade 3 (Severe): Inadequate oral caloric or fluid intake; tube feeding, TPN, or hospitalization indicated

Assessment and Grading

Clinical

Does this patient have any existing issues with appetite caused by the cancer state, other clinical issues, or an eating disorder?

Characterize the symptom (onset, pace)

Ask the patient:

Is this a new or worsening symptom? When did it start or get worse? Has it developed gradually or suddenly? Have you experienced any taste changes? Are you trying to eat 3 large meals or eating small amounts throughout the day (snack-size)? Are you doing any light exercise, stretching, walking, etc? Are you avoiding foods with strong aromas?

Grade the symptom

Ask the patient:

Are you still able to eat your normal foods? Have you lost weight? Are you very weak or faint?

Patient Query Regarding Other Symptoms/Red Flags

Ask the patient:

Are you feeling faint/dizzy, passing out, having trouble thinking? Are you in intense pain? Do you have any abdominal (belly) pain? Are you overly sleepy? Do you have any yellowing of the skin/eyes?

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 moderate or worse anorexia should be seen.

    For any red-flag symptoms, the patient should be seen immediately.

    Patients who are passing out or who have intense abdominal pain should go to the ED (they should be driven).

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    Nursing Assessment of Potential Causes

    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)

    Mucositis & Xerostomia - Nursing Assessment

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

    Thyroiditis - Nursing Assessment

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

    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?

    Differential Diagnosis

    What do you suspect is the cause of the loss of appetite?