Symptom Assessment

Although the findings are used throughout the cancer care team, conducting symptom assessments is typically a nursing responsibility. Oncology nurses specifically use symptom assessments to evaluate a patient, and their findings are often communicated to other members of the interprofessional care team. Together, healthcare professionals develop a detailed plan of care for patients with cancer and manage their reported symptoms.

The Oncology Nurse’s Role in Symptom Assessment

Symptom assessment involves taking a detailed history from the patient to understand the cause and severity of a symptom, including information about the patient’s past and current diagnoses and healthcare-related quality of life. A variety of validated assessment tools and resources are available to identify and assess cancer-related symptoms, including guidelines from ONS and other national organizations as well as individual institutions’ assessment resources (see sidebars).

ONS member Jessica Leibelt, MSN, NP-C, AOCNP®, nurse practitioner at the Oncology Institute of Hope and Innovation in St. Petersburg, FL, said she typically conducts symptom assessments at the beginning of a patient’s visit. “In a clinic setting, that’s before seeing the physician; in inpatient care, it would be at the beginning of a nurse’s shift; and in infusion, it’s during the initial conversation before obtaining IV access,” she said.

“Often, nurses are the first members of the interprofessional care team to connect with a patient at a visit where an assessment is being conducted,” Leibelt added, and that the first evaluation allows oncology nurses to form a relationship with their patient that fosters comfort with and trust in the interprofessional care team.

“The oncology nurse is the true eyes and ears of the oncology team,” Leibelt said. “It’s no secret that nurses form the deepest bonds with patients because of the time that they spend with them. This means that patients generally let their guard down with their nurses and tell them everything, including the truth about how they are feeling.”

ONS member Kris Mathey, MS, APRN-CNP, AOCNP®, advanced practice provider manager, fellowship director, and gastrointestinal medical oncology nurse practitioner at the James Cancer Hospital and Solove Research Institute at Ohio State University in Columbus, said that at her institution, an oncology RN will complete a symptom assessment flowsheet in the patient’s electronic health record, which physicians and other members of the interprofessional care team reference while managing and prescribing care.

“It’s important for the oncology nurse to conduct a thorough symptom assessment and communicate their findings efficiently with the interprofessional care team, as it can lead to quicker and higher-quality care for the patient,” Mathey said.

Symptom Assessment Involves the Entire Care Team

Mathey said that at her institution, RNs and nurse practitioners work together to manage patients’ cancer-related symptoms. In her experience as an APRN, she relies on RNs for a first assessment and listens for the key words that patients report to determine the best approach.

“A detailed symptom assessment helps direct my plan and assessment even before I see the patient and guide what symptoms I should focus on and narrow down,” Mathey said. “I may have an idea or plan in my head before I even see the patient, thanks to the RN’s initial symptom assessment. Sometimes the patient will tell the RN one thing and me another, so I am able to clarify and have the patient expand on those differences during my assessment.”

For example, if a patient reports experiencing fatigue to their RN, the APRN will review the patient’s initial symptom assessment and develop follow-up questions to help them develop a course of action. Questions an APRN may ask a patient in a fatigue scenario include:

• Your RN told me that you are having some fatigue. Can you expand on that?
• Are you taking multiple naps a day? Do you feel rested after?
• While you feel tired, are you still able to bathe yourself, make yourself a small meal (like a bowl of cereal), or dress yourself on your own?

Nurses have a gut instinct to tell when something is different, and communication with patients and the interprofessional care team is key when conducting and interpreting symptom assessments.

At Mathey’s institution, nurse practitioners evaluate RNs’ symptom assessments and a patient’s reported symptoms to determine whether the symptoms are related to the patient’s disease, treatment, a comorbid illness or condition, or a combination of all three. If the symptom is related to a comorbidity, the assessment may help the nurse practitioner identify the underlying condition. Nurse practitioners also compare current assessments to previous ones to ensure a patient’s symptom management plan is effective.

“Is the patient’s fatigue level worse? Is their neuropathy graded better or worse?” Mathey said. “If an RN reports to me that the patient feels fatigued and weak, and I did not see them at their previous visit, I compare the assessment to the previous visit. If their performance status was similar, it does not concern me as much as seeing a huge change in assessment.”

With an in-depth symptom assessment on hand, nurse practitioners and other members of the interprofessional care team have a quick reference when a patient needs more urgent intervention. Both Leibelt and Mathey emphasized the importance of involving all providers contributing to a patient’s care—oncology nurse, physician, and other members of the interprofessional care team, such as clinical pharmacists and cardiologists—to identify evidence-based approaches for symptom management.

Tools and Guidelines Help Standardize Symptom Assessment

“Nursing education is very focused on symptom assessment,” Leibelt said. “Although physicians and advanced practice providers are well-trained on symptom management, they are also trained to perform differential diagnosis and treatment, which becomes the focus of their work. Especially when there are great oncology nurses performing preliminary, high-quality assessments.”

Evidence-based and peer-reviewed guidelines help nurses recognize signs and symptoms, perform assessments, and answer critical questions and concerns from patients and providers. The ONS Guidelines^TM consolidate evidence-based symptom management recommendations for patient care and incorporate published research and expert consensus on patient preferences and values. The guidelines are for individual-use only and are available to registered providers with an ONS account in all specialties—not just oncology.

“The ONS Guidelines can also be beneficial for nurses outside of the oncology specialty because patients with cancer are encountered in every specialty,” Leibelt said. “Nurses who are not experienced in oncology need to be able to access quality information on the symptoms patients with cancer experience to best support them.”

See the sidebar for links to each Guideline and a contact for learning how to use them on an institution-wide level.

Leibelt served on a panel of oncology professionals that developed the ONS Guidelines for Treatment-Related Hot Flashes in Women With Breast Cancer and Men With Prostate Cancer. “Guidelines like ONS’s can help healthcare professionals build on symptom assessment to determine the right treatment and management of a patient’s symptoms, in this case hot flashes,” she explained.

Leibelt also recommended that providers bookmark the guidelines on their computers to reference in real time. And in addition to reviewing each ONS Guideline’s clinical summary companion article, which offers a quick overview of best practices, Leibelt suggested reading the entire guideline to understand how the panel evaluated the evidence and came to its conclusions and recommendations. Fully understanding the guideline and approach will help nurses better use them in interprofessional team discussions about managing a patient’s symptoms.

Patients with cancer may experience a multitude of symptoms and side effects related to their diagnosis or treatment, and comprehensive assessments guide care coordination and interprofessional management to improve outcomes. The oncology nurse’s role in assessment, interpretation, and leadership is vital in creating a positive impact on a patient’s quality of life and care.

“My advice for nurses who are looking to create their own procedures or processes on symptom assessments, management, and grading tools at their own institutions is to start at the source of expert oncology nursing care,” Leibelt said.

“Nurses have a gut instinct to tell when something is different, and communication with patients and the interprofessional care team is key when conducting and interpreting symptom assessments,” Mathey said. “Poorly documented or assessed symptoms are more likely to go untreated, and if we all work together, we can get better outcomes for our patients. That is the ultimate goal.”