Symptom: Blisters

Initial Grading Reminder

CTCAE grading of blisters:

Grade 2 (Moderate): Skin changes (e.g., peeling, blisters, bleeding, edema, or hyperkeratosis) with pain; limiting instrumental ADLs
Grade 3 (Severe): Severe skin changes (e.g., peeling, blisters, bleeding, edema, or hyperkeratosis) with pain; limiting self-care ADLs

Assessment and Grading

Characterize the symptom (onset, pace)

Ask the patient:

What is the location of the blisters? When did they start? Did they develop gradually or suddenly? Any fever or chills?  Any new medications, OTCs, herbals, or topicals?

Grade the symptom

Ask the patient:

Please send a photo, if possible. Describe your blisters. How much of your body is covered? Are they limiting your ability to take care of yourself, get dressed, or do the things you want to do?

Patient Query Regarding Other Symptoms/Red Flags

Ask the patient:

Do you have any blisters in the mouth or the rectum? Is your skin peeling? Is there a string of blisters in a line? Are they painful? (suggesting zoster)

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 any blisters 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)

    Differential Diagnosis

    What do you suspect is the cause of the blisters?