Symptom: Bowel Movement Changes

Initial Grading Reminder

CTCAE grading of 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 any history of GI problems? Is this a new or worsening symptom? When did it start or get worse? Has it developed gradually or suddenly? Are you taking any medications/OTCs/supplements for your bowel movements? Are you taking marijuana? What else have you done/taken for this symptom?

Suddenly would be more consistent with peritoneal signs.

Grade the symptom

Ask the patient:

How much blood and mucus is in the stool? How have your bowel movements been?  What is your normal baseline? How many bowel movements per day do you have now?

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 bowel movement changes are 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 the bowel movement changes?