Symptom: Joint, Swelling

Initial Grading Reminder

CTCAE Criteria for Grading Joint Swelling:

Grade 1: ≤25% loss of ROM (range of motion); decreased ROM limiting athletic activity
Grade 2: >25 – 50% decrease in ROM; limiting instrumental ADLs
Grade 3: >50% decrease in ROM; limiting self-care ADLs; disabling

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? Have you had any joint issues in the past? How much worse is it now? Has it developed gradually or suddenly?

Grade the symptom

Ask the patient:

Which joint is bothering you? How unstable is your joint? Can you put weight on it? Do you feel like you need something to stabilize you when you walk, like a cane or walker?

Patient Query Regarding Other Symptoms/Red Flags

Ask the patient:

Have you fallen or felt like you might fall?

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 moderate or worse joint swelling should be seen. Patients with any of the red-flag symptoms should be seen immediately.

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    Nursing Assessment of Potential Causes

    Arthralgias and Arthritis - Nursing Assessment

    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Does the patient appear uncomfortable?
    • Does the patient appear unwell?
    • Is gait affected?
    • Obvious swollen or deformed joint(s)?
    • Is the patient having trouble getting up and down stairs?
    • Have symptoms worsened?
    • Are symptoms limiting ADLs?
    • Are symptoms increasing the patient’s risk for fall? Other safety issues?
    • Associated symptoms?
      • Fatigue (new or worsening)
    • Is there a pre-existing autoimmune dysfunction?
    • Is there a history of prior orthopedic injury, DJD, OA, RA?
    • Other immune-related adverse effects
    • Three subtypes of inflammatory arthritis associated with checkpoint inhibitors:
      1. Polyarthritis similar to rheumatoid arthritis
      2. True reactive arthritis with conjunctivitis, urethritis, and oligoarthritis
      3. Subtype similar to seronegative spondyloarthritis with inflammatory back pain and predominantly larger joint involvement

    Differential Diagnosis

    What do you suspect is the cause of the joint swelling?