Symptom: Breathing Difficulty

Initial Grading Reminder

CTCAE grading of breathing difficulty:

Grade 1 (Mild): Shortness of breath with moderate exertion
Grade 2 (Moderate): Shortness of breath with minimal exertion; limiting instrumental ADLs
Grade 3 (Severe): Shortness of breath at rest; limiting self-care ADLs
Grade 4 (Life-threatening): Urgent intervention indicated

Assessment and Grading

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 had any difficulty breathing in the past? How much worse is it now? Do you have asthma or emphysema? 

Grade the symptom

Ask the patient:

When are you short of breath? Are you short of breath at rest or only when you do something like walk or go up the stairs? If you take it easy, does it get better? Is it affecting your ability to take care of yourself?

Patient Query Regarding Other Symptoms/Red Flags

Ask the patient:

Do you have any chest pain? Any swelling in your legs? Do you have any weakness or numbness or tingling?

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

    A patient with severe or life-threatening SOB  or new-onset SOB needs to be seen immediately, with an ED referral as necessary.

    Patients with any of the red-flag symptoms need to be seen immediately. Patients with chest pain need to go to the ED.

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    Nursing Assessment of Potential Causes

    Pneumonitis - Nursing Assessment

    • Look
    • Listen
    • Recognize
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    • Look
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    • Recognize
    • Does the patient appear uncomfortable?
    • Did the patient have difficulty walking to the exam room? Or going up stairs?
    • Does the patient appear short of breath?
    • Is the patient tachypneic?
    • Does the patient appear to be in respiratory distress?
    • Has the patient noted any change in breathing?
    • Does the patient feel short of breath?
    • Does the patient note new dyspnea on exertion?
    • Does the patient notice a new cough? Or a change in an existing cough?
    • Have symptoms worsened?
    • Are symptoms limiting ADLs?
    • Associated symptoms?
      • Fatigue
      • Wheezing
    • Is the pulse oximetry low? Is it lower than baseline or compared with last visit? Is it low on exertion?
    • Is there a pre-existing pulmonary autoimmune condition (i.e., sarcoidosis)?
    • Is there a history of prior respiratory compromise (e.g., asthma, COPD, congestive heart failure)?
    • Has the patient experienced other immune-related adverse effects?

    Neuropathy - Nursing Assessment

    • Look
    • Listen
    • Recognize
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    • Recognize
    • Look
    • Listen
    • Recognize
    • Does the patient appear weak?
    • Does the patient appear uncomfortable?
    • Altered ambulation or general movement?
    • If muscular weakness is present, any respiratory difficulties apparent?
    • Does the patient report weakness (unilateral or bilateral)?
    • Does the patient report new or worsened pain, numbness, or tingling?
    • Does the patient report difficulty walking or holding items?
    • Motor deficits
    • Sensory deficits
    • Mental status changes
    • Paresthesias
    • Laboratory values
    • Does the patient have diabetes mellitus?
    • Are there neurologic signs and symptoms?
    • Results of prior imaging
      • Metastases to spinal cord
      • Other metastases that may cause symptoms

    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 breathing difficulty?