Symptom: Fever

Initial Grading Reminder

CTCAE grading of fever (note this is different than pyrexia associated with targeted therapies):

Grade 1: 38.0 – 39.0 °C (100.4 – 102.2 ° F)
Grade 2: >39.0 – 40.0 °C (102.3 – 104.0 ° F)
Grade 3: >40.0 °C (>104.0 ° F) for ≤24 hrs
Grade 4: >40.0 °C (>104.0 °F) for >24 hrs

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 exposure to sick individuals? Do you have other symptoms suggesting an infection (e.g., sore throat, cough, runny noise)? Any associated flu-like symptoms (fatigue, chills, decreased appetite)?

Grade the symptom

Ask the patient:

How high is your temperature? How long have you had the fever? Have you taken any medications to reduce the fever?

Patient Query Regarding Other Symptoms/Red Flags

Ask the patient:

Do you have any diarrhea and severe abdominal (belly) pain or bloating? Are you feeling faint? Do you have yellowing of the skin? Do you have a headache or any vision problems? Any chills or flu-like symptoms?  Are you able to hydrate?

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 new onset moderate or worse (or worsening) fever 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
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    • Recognize
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    • 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)

    Pneumonitis - Nursing Assessment

    • Look
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    • Recognize
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    • 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?

    Hypophysitis - Nursing Assessment

    • Look
    • Listen
    • Recognize
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    • Recognize
    • Look
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    • Recognize
    • Does the patient appear fatigued?
    • Does the patient look listless?
    • Does the patient look ill?
    • Does the patient look uncomfortable?
    • Does the patient report:
      • Change in energy?
      • Headache?
      • Dizziness?
      • Nausea/vomiting?
      • Altered mental status?
      • Visual disturbances?
      • Fever?
    • Low levels of hormones produced by pituitary gland (ACTH, TSH, FSH, LH, GH, prolactin)
    • Brain MRI with pituitary cuts: enhancement and swelling of the pituitary gland
    • DDX adrenal insufficiency: low cortisol and high ACTH
    • DDX primary hypothyroidism: low free T4 and high TSH

    Nephritis - Nursing Assessment

    • Look
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    • Recognize
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    • 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?

    Hepatotoxicity - Nursing Assessment

    • Look
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    • Recognize
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    • 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)

    Infusion Reaction

    Itching, flushing, difficulty breathing? Is he/she feeling faint?

    Differential Diagnosis

    What do you suspect is the cause of the fever?