Symptom: Chills/Shaking

Initial Grading Reminder

CTCAE grading of chills/shaking:

Grade 1 (Mild): Mild sensation of cold; shivering; chattering of teeth
Grade 2 (Moderate): Moderate tremor of the entire body; narcotics indicated
Grade 3 (Severe): Severe or prolonged, not responsive to narcotics

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 chills/shaking in the past? How much worse is it now? Has it developed gradually or suddenly?

Grade the symptom

Ask the patient:

How bad are your shakes? What part of your body is involved?  Do you have a fever?

Patient Query Regarding Other Symptoms/Red Flags

Ask the patient:

Do you have any back pain, itching, flushing, or difficulty breathing? Are you feeling faint?

Note: These symptoms are consistent with an allergic reaction.

Did you black out or become incontinent?

Note: It is important to rule out a seizure.

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 or worse chills/shaking should be seen.

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

    For symptoms suggestive of an allergic reaction, the patient should be seen immediately. For patients who had a reaction during the actual infusion, hospitalization is indicated for clinical sequelae.

    Patients exhibiting symptoms of a seizure should be seen immediately.

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    Nursing Assessment of Potential Causes

    Highly suggestive of infusion reaction outside of infectious/febrile/ or neurologic causes

    Differential Diagnosis

    What do you suspect is the cause of the chills/shaking?