Question on neutropenic precautions

  1. Hi all,
    I'm working on a project for class and am not certain about what is and is not allowed when a pt is on neutropenic precautions.

    The scenario is this: Pt is 60-something with leukemia. She finished 2nd round of chemo 10 days ago. Platelets are 28, H&H is 10.2 and 43, WBC is 1.4. She has continuous epidural cath for pain, running in Fentanyl and Bupivicaine at 2cc/hour. She requests to ambulate in the halls and shower.

    That is all the info I have. I understand that sometimes the pt can ambulate outside of their room if they wear a mask. Is this an agency policy? Assuming this pt's hospital does allow ambulation with a mask and assuming I have no dr. order one way or another, what would you do?

    I tend to think this gal shouldn't be up and walking the halls when she's anemic, neutropenic, and thrombocytopenic -- right smack dab in the time period when her bone marrow suppression is at its worst. Would you let her go or not? If two people were assisting her ambulation, would you let her go then?

    Thanks for your help.
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  2. 8 Comments

  3. by   majrn
    Really you need more info. What is the definition of neutropenia. At our facility it is when the absolute granulocyte count is less than 500. To figure that you need a differential on the CBC. With the information you have supplied I see no reason she couldnt walk in the hall assisted with a mask on. I wouldnt let her shower with an epidural cath. If she has the strength to walk she should. Of course setting limits to where she may walk.
  4. by   bargainhound
    I would think she should not be out of her room and hope there is a shower in her room. If not, I would restrict her to sponge bath until lab work improved.
  5. by   srose
    I work on a bone marrow/stem cell transplant unit, where all of our patients are neutropenic. They shower every day, and are encouraged to walk the hall at least once a day. They don't wear masks or gowns in the halls unless they are on droplet or contact isolation to protect the other patients. Of course they usually cannot leave our unit. I remember learning in school and orientation that most infections they get are usually from their own flora anyway.

    What kind of unit is your patient on? On a general med-surg floor, I don't think I'd let her walk the halls. Ours is probably different since we follow standard and neutropenic precautions for the entire floor, air is hepa filtered, etc.

    Rose
  6. by   Ted
    I would think neutropenic precautions vary from facility to facility.

    I think the ANC had to be greater than 500 before they could leave their private rooms. (Understand I USED to work on a heme/onc/bmt floor. . . 5 years ago. . . and memory fails me so. . . ) Then they could walk around the unit (outside their room) with a mask.

    This thread is bringing me down "memory lane". I've cared for many-a-brave soul (leukemics, BMT pts, oncology in general pts) who underwent the grueling process of chemo or chemo/radiation! Memories. . . some happy. . . some sad. Mostly sad, though.

    Ted
  7. by   ?burntout
    Hmmmmm....I would think that she would be ok to walk in the halls granted she wore a mask and gloves...possibly a gown as well. If she is on a med/surg floor-would keep her away from ANY other isolation rooms. I would just check with the MD and your hospital's policy.

    However I definately wouldn't let her shower with an epidural cath....Just asking for an infection if that was to get wet or soiled

    Also at our hospital, we do not allow fresh fruits or veggies or live plants in their rooms...because of any type of microbe.
  8. by   PJMommy
    Thanks all! This helped tremendously.
  9. by   caroladybelle
    I have 8 years of Onco/BMT/HIV experience and am a certified Onco nurse.

    Policies vary from hospital to hospital.

    However, you need to have the white count differential to determine actual degree of neutropenia. The white count is not sufficient. Most places start minimal neutropenia precautions at ANC<1500, but are much stricter with ANC<500. As your patient has a WBC 1.4, even if the granulcytes were 100% (which they probably are not), the ANC will not be above 1400.

    In virtually all facilities that I have worked in, exercise several times per day was encouraged if not mandatory, to prevent DVT's, GI distress and life threatening respiratory infection. The only absolute contraindication would be a platelet count less than 10-15, due to risk of spontaneous bleeds. ALL nontransplant patients were required to ambulate in the hall with gloves, slippers and a mask on. They were also encouraged to take a daily shower with their IV access covered. I, however, have had few patients with a epidural that were not bed ridden so I cannot speak to that issue. But I would think that the epideral could be covered more adequately than IV ports and central lines, and those patients were showering daily. And many of my patients have virtually no registerable ANC whatsoever (WBC <0.2 and 0 Neutrophils.

    I am surprised about the epideral. Most of my physicians are reluctant to place an epideral in a pt that has the potential for an extremely low platelet count or other clotting problems. Onco patients have higher risk also of DIC, or DVTs requiring anticoagulation, commonly contraindicating epiderals, due to hemmorhage risk. But as the epideral line is generally accessed less than the IV, I do not believe that it is as much of an infection risk, comparatively speaking.

    Other precautions: No fresh salads, no fresh fruit that cannot be peeled (must be peeled), no fresh flowers from garden (most reputable florists get theirs through "clean" regulated sources, theoretically), and no plants with soil (though, again, most florists get "sterilized" soil). In many areas, bottled water of reputable quality is used rather than tap - and definitely warn against use of well water at home. Ice can be a problem - if there is a frig in the room, I freeze a bottle of water and put it out to melt at night, so that they have cold water through the night. Do not use straws (can grow bacteria) and change disposable cups frequently. No children on floor (NO CHILDREN ON FLOOR!!!!). All healthcare workers and visitors wash hands with betadine or hibeclens coming into room and leaving. Those that are sick do not enter, those that have allergies, have to wear a mask.

    Allo transplant rules are stricter, and they do not leave the room, but they still shower with hibeclens daily and they have a exercycle in the room that they are required to use daily, barring platelets less than 10-15.

    While we worry about the germs in the air, my personal observations (especially with the chemo for "liquid" tumors - lymphoma, leukemia and myeloma which generally has the most severe bone marrow supression), is that if these do not exercise, they are MUCH more likely to die of infection or other preventable complications. While some days, it seems cruel to force them to walk and shower, I have seen that leukemics that we do not push are invariable the ones that have bowels that obstruct, the DVTs and severe respiratory infections. And these things can kill them.

    It also promotes a much healthier mindset to have them shower daily and walk in the hall like a normal person. And that healthy mindset will go far to curing them.

    My spiritual belief is that G-d does not intend for our bodies to lie there. When we rest too much, our bodies do not work as they should. And we need to push our pts sometimes or we are doing them a disservice.

    Just my opinion and experience.
  10. by   crimz
    As far as I know she's allowed to ambulate around the hall if she's wearing a mask and for the shower well she can because being on isolation she would have to have her own room with her own shower....

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