Symptom: Blood/Mucus in the Stool

Initial Grading Reminder

CTCAE grading of blood in stool (bowel movement changes):

Grade 1 (Mild): Asymptomatic; clinical or diagnostic observations only; intervention not indicated
Grade 2 (Moderate): Abdominal pain; mucus or blood in stool
Grade 3 (Severe): Severe abdominal pain; change in bowel habits; medical intervention indicated; peritoneal signs
Grade 4 (Life-threatening): Life-threatening consequences; urgent intervention indicated

Assessment and Grading

Characterize the symptom (onset, pace)

Ask the patient:

Do you have a history of hemorrhoids? Of hard stools/constipation? Is this a new or worsening symptom? When did it start or get worse? Has it developed gradually or suddenly? Have you had a change in diet in the past day or so?

“Suddenly” would be more consistent with peritoneal signs.

Grade the symptom

Ask the patient:

How much blood and mucus is in the stool? Do you see blood on the toilet paper or actually in your stool? Have your bowel movements been different in other ways?

Patient Query Regarding Other Symptoms/Red Flags

Ask the patient:

Do you have any abdominal (belly) pain/tenderness, nausea, fever, or decreased appetite?

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 blood in the stool is moderate/severe, the patient should be seen.

    If patients have any of the red-flag symptoms, they should be seen for GI workup or referred to the ED.

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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)

    Differential Diagnosis

    What do you suspect is the cause of blood/mucus in the stool?