Symptom: Bruising Easily

Initial Grading Reminder

CTCAE grading of bruising:

Grade 1 (Mild): Localized or in dependent area
Grade 2 (Moderate): Generalized

Assessment and Grading

Characterize the symptom (onset, pace)

Ask the patient:

Do you have any kidney/liver problems? Are you on blood thinners? Is this a new or worsening symptom? When did it start or get worse? Has it developed gradually or suddenly?

Grade the symptom

Ask the patient:

Please send a photo, if possible. Where are you bruising? How many bruises do you have?

Patient Query Regarding Other Symptoms/Red Flags

Ask the patient:

Do you have any pain in your abdomen (belly), bloating, sleepiness, or yellowing of skin? Is your thinking clear or do you feel foggy?

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 moderate bruising should be seen.

    Patients with any of the red-flag symptoms need to be seen immediately.

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    Nursing Assessment of Potential Causes

    Hepatotoxicity - Nursing Assessment

    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Does the patient appear fatigued or listless?
    • Does the patient appear jaundiced?
    • Does the patient appear diaphoretic?
    • Does the patient have any ascites?
    • Change in energy level?
    • Change in skin color? Yellowing?
    • Change in stool color (paler)?
    • Change in urine color (darker/tea colored)?
    • Abdominal pain: specifically, right upper quadrant pain?
    • Bruising or bleeding more easily?
    • Fevers?
    • Change in mental status?
    • Increased sweating?
    • Elevation in LFTs
      • AST/SGOT
      • ALT/SGPT
      • Bilirubin (total/direct)
    • Alteration in GI function
    • Symptoms such as abdominal pain, ascites, somnolence, and jaundice
    • Other potential causes (viral, drug toxicity, disease progression)

    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 increased bruising?