Symptom: Diarrhea

Initial Grading Reminder

CTCAE grading of diarrhea:

Grade 1: Increase of <4 stools per day over baseline; mild increase in ostomy output compared with baseline
Grade 2: Increase of 4–6 stools per day over baseline; moderate increase in ostomy output compared with baseline
Grade 3: Increase of ≥7 stools per day over baseline; incontinence; hospitalization indicated; severe increase in ostomy output compared with baseline; limiting self-care ADLs
Grade 4: Life-threatening consequences; urgent intervention indicated
Grade 5: Death

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? Have you started any new medicines? Does anyone in your household have diarrhea/vomiting?

Grade the symptom

Ask the patient:

How frequently are your bowel movements? How much have they increased over your normal? Are you having accidents? Are you feeling faint? Are you able to keep water down? Are you urinating?

Patient Query Regarding Other Symptoms/Red Flags

Ask the patient:

Do you have any abdominal (belly) pain? Any nausea or vomiting? A fever? Do you feel like your heart is racing? Do you feel hot?

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 even mild diarrhea should be seen.

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

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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)

    Thyroiditis - Nursing Assessment

    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Does the patient appear unwell?
    • Changes in weight since last visit
      • Appear heavier? Thinner?
    • Changes in hair texture/thickness?
    • Appearing hot/cold?
    • Does the patient look fatigued?
    • Appetite/weight changes?
    • Hot or cold intolerance?
    • Change in energy, mood, or behavior?
    • Palpitations?
    • Increased fatigue?
    • Bowel-related changes?
      • Constipation/diarrhea
    • Skin-related changes?
      • Dry/oily
    • Ensure that patient undergoes thyroid function tests prior to first dose, every 12 weeks while on PD-1 therapy and q3 weeks with ipilimumab
    • High TSH with low free T4 consistent with primary hypothyroidism
    • DDX: secondary hypothyroidism due to hypophysitis, low TSH and low free T4
    • Occasionally thyroiditis with transient hyperthyroidism (low TSH and high free T4) may be followed by more longstanding hypothyroidism (high TSH and low free T4)
    • Other immune-related toxicity?
    • Prior thyroid dysfunction?

    Differential Diagnosis

    What do you suspect is the cause of diarrhea?