Caring for a neutropenic pt

evergreener · Mar 24, 2006

Here is some information I found from reading my texts and visiting other discussions on this site. I tried to summarize the important aspects of caring for a neutropenic pt with professional literature. There is more info to come, but I wanted to make sure I hit the big points. Thanks in advance for reading it...I hope you learn something new from it.

I Prevent Infection

a) WASH HANDS!!!!! (thoroughly and constantly!)

b) Know pts neutrophil status to determine need for additional

precautions

(Neutropenia is defined as

neutropenia is

c) Implement contact precautions/reverse isolation

(I have read that there is no evidence to suggest that these precautions have

been successful and that some hospitals choose not to use them to save $

and to make pt more comfortable (I guess so the pt doesn't feel like E.T.--in

the final scene). Anyone experience this at their hospital? I think its mostly in

Europe.)

d) Restrict diet to avoid possibly contaminated foods (salads & fresh

fruits, etc)

(again, no evidence found that suggests this is helpful. I also see pts getting

fruit juices still...would this matter? I found that 95% of juices are

pasteurized, but often not labeled. See this link for more info:

http://www.metrokc.gov/health/foodsfty/pasteurizedjuice.htm)

II Report signs of infection and follow treatment protocol

a) Fevers >100.4 are reported in neutropenic pts (is this pretty standard?)

b) Start antibiotics immediately if fever is >100.4 (I saw on other postings that Vanco is used...is that normally the case? What other antibiotics are common? I assume the docs prescribe broad-spectrums. Also, what do you culture if you don't know where the infection is?)

My pharmacology book suggests IV Cefriaxone plus amikacin for initial empiric therapy (Lehne, 2004)...does anyone follow this suggestion in their practice?

III Neupogen if necessary to increase WBC

a) usually not given to Leukemia pts (because it proliferates the

cancerous cells of the bone marrow) However, I did read that in pts with

acute myelogenous leukemia, neupogen has been given to stimulate division

of cancer cells, thereby making them more sensitive to chemotherapeutic

agents (Lehne, 2004). This goes back to getting those cells out of the Go

phase and into the active cell cycle to kill 'em off!

b) can cause resp depression (I saw this in my Mosby's Drug Guide for

Nurses (2005) and I looked it up in my Pharmacology text book but this one

did not mention resp depression as an adverse effect. I want to know the

pharmacology behind the respiratory depression. Does anyone know

why this drug would cause it? I cannot make the connection.)

c) very expensive $1800-2800 per treatment...Yikes! (As nurses, do you

see this drug equally prescribed to pts in need...or just to the ones with

good insurance coverage?)

IV Other things to be aware of in the neutropenic pt

a) thrombocytopenia goes along c the neutropenia r/t bone marrow

suppression, so don't give aspirin or other anticoagulants, and assess for

bleeding, take extra precautions to avoid bruising, etc.

b) anemia may also be present

c) remember psychosocial needs too!

leslie :-D · Mar 25, 2006

i don't know about the respiratory depression, but a rare se of neupogen is anaphylaxix and/or trouble breathing. just something you need to monitor when you have a pt you takes this.

leslie

mom4josh · Mar 27, 2006

At my hospital, vancomycin is never used as a first line of defense for neutropenia. In fact, it is only used if a culture has grown MRSA or if other antibiotics have not been successful. Our standard for neutropenia is doing blood cultures, stool culture if patient is having diarrhea, and urine culture/urinalysis. Then patient is started on Timentin or some other broad-spectrum antibiotic as well as Neupogen (have never seen any respiratory depression or other reaction from this either). And no, order for Neupogen is not dependent on ability to pay.

A sign is placed on the patient's door for no fresh fruits or vegetables (juices are okay), no IM or PR meds, no plants or flowers, and no sick visitors or babies/children in room.

Iluvhospice · Mar 29, 2006

We post signs on the door advising sick visitors (states specifically with a COLD or respiratory infection because people with colds generally don't consider themselves "sick") not to enter. Masks are only required of nursing staff if one of us has a cough/cold/sore throat. Handwashing with soap and water is required before and after.

Generally blood cultures are the first order - then start an antibiotic - usually Zosyn until cultures come back. If cultures are positive, then infectious disease MD is called in on the case.

All of our patients who are neutropenic secondary to chemo get Neupogen. Ability to pay is not considered. Nobody is turned away because of inability to pay - the docs don't care if the hospital gets reimbursed, that's the reason that their uninsured patients become OUR inpatients for chemo or blood transfusions that could be handled as outpatients! (but that's another rant!)

Hope this helps.

caroladybelle, BSN, RN · Mar 30, 2006

I am a traveler that works exclusively in oncology/hematology.

My current assignment requires us wear a mask in all of our patients' rooms during flu/rsv season. As well, all of our visitors must wear a mask (and it is enforced).

The patient wears a mask, whenever out of the room.

All blood draws/central IV tubing changes are done after setting up a sterile field and using sterile gloves (even though one never touches the ends).

The general rule is no uncooked vegetables, raw unpeeled fruits, food from home, that is not hot. No reheating meals in the communal microwave. No real flowers, live plants. No children under 6 on the unit (unless the patient is dying). Patient needs to shower at least daily and put on fresh clothes daily. Laundry to be washed in hot water, dishes washed in hot water, with bleach in the rinse, or use a dishwasher. No raw honey/raw milk/soft cheeses/raw meats. Nails to be filed, not cut. No tampons permitted and pads must be changed 4-6 times a day or more. No shared makeup, and fresh makeup should be bought. The patient should have dental work done before chemo initiates. It is preferred that the patient not use contact lens. No water pitchers permitted, no cups reused and prefer no use of straws. patient must wear slipper socks/shoes whenever OOB. Unless the patient is severely anemic (HCT less than 23-25%, platelet count less than 10K), the patient should walk laps/use tread mill/use stationary bike/etc.) Patient should be OOB at 4-8 hours a day or more.

These rules vary by institution. I currently work at a facility that is currently rated in the top 5 in the nation, on a hemo floor, with large numbers of refractory leukemics. Most of the patients have extended periods of ANC of 0-80, sometimes to the point of doing granulocyte transfusions. And as they are resistant hemo cancer, neupogen is generally not going to be option.

Nesher, BSN, RN · Apr 2, 2006

Interesting to read everyones replies. I work on a stem cell transplant unit and I guess because we've been doing them longer than anyone else in the country we aren't quite as severe. It may also be that because we treat all the pt's the same and can enforce rules for the entire unit. Large floor signs warn that noone can enter if ill. For example everyone must sign in as they enter the floor - visitors, dietary, families, doc, nurses, etc - what they are attesting to is that that have no s/s of the flu. They and we as staff are not allowed to come to work if we have a fever or cannot control our symptoms (runny nose, cough).

Our dietary dept treats the food our pts get differntly than the rest of the hosptial. They wash fruits and veggies and to be honest I don't know exactly how they do this, but as result they can have it - salads come up wrapped as does fruit( in saran wrap). There are alot of things they cannot have such as sprouts.

We change our water pitchers daily for everyone. If someone wants ice we don't take the pitcher into the nourishment room, we fill a plastic bag with ice and bring it into the room. Only staff is allowed in the nourishment room.

Our pts don't wear masks unless they have have s/s of cold. At which point they go into droplet isolation (masks with shield gown gloves) for people entering room, we sent a npt to test for flu. They are in isolation for 5 days until the results come back.

Contact isolation is used for cdiff, VRE, MRSA.

We start folks on levo or ceftazidime when their counts drop below 500. At the first neutropenic fever (38.3) we do cultures of their hickmans, urine and chest xray - the antibiotic is then changed - not to vanco first thing - usually to something like imipenum.

Our entire unit has a policy of no flowers, plants, fake flowers with moss etc. This policy is something they are aware of before they are admitted.

Kids of all ages are allowed but they will get htier little hands washed and even be put in a gown ( they kinda love this !) - they don't last long in the room but it better than cutting off the pt. Alcohol based cleaner with moisturizer is very popular with the group as well.

MrsStraty · May 2, 2006

I too work on BMT unit and we start Vanco and Fortaz at the 1st neutropenic fever, right after the blood cultures are drawn that is. We culture anything that can be cultured. We have the no fresh flowers rule, no flowers at all actually. No fresh fruit or salads either. Our patients wear masks while out of their room, visitors are limited, I have never seen a nurse be sent home because they were too sick to work on the BMT floor, they just are told to wear a mask in the patient rooms.

We give Neupogen also, haven't seen a reaction with Neupogen, just with Leukine and we sometimes give that instead of Neupogen. We transfuse platelets under 10,000.

Carlissa

glb1960 · May 10, 2006

I work on a peds BMT and most of what is written is pretty close to what we do,as well. Some differences are the HEPA filtered pressurized rooms that the pts. stay in, limitimg total visitors at all times to 3 in the room, clindamycin with fevers and weekly scheduled screening of specimens of throat, stool, urine and blood.

hem · May 17, 2006

i work in an outpatient BMT program where both allo and autologous transplant patients are seen daily at the start of their transplant treatment protocols. Patients continue to be outpatients until an inpatient admission is required. A fever is usually the reason for admissions in the early phases of transplant. If patient is stable we give IV ceftriaxone 1 gm q 24 hours. However, if fevers persist, cultures are positive or patient becomes unstable they are admitted for pip/tazo or treatment specific to culture sensitivity.

We use neupogen day +7 for all of our autologous bmt patients. this is covered under the hospital admission. although, i am in Canada, so insurance is not an issue for our transplant patients when they are undergoing therapy as an inpatient.

mayflower2000, RN · May 17, 2006

I work here in europe in hematology. We use gentamycin and tazocin as our

first line of antibiotics. We only use vancomycin if the blood culture result

is positive of mrsa. Patients are put on isolation if they are having bone

marrow transplant.We adhere to strict handwashing policy before entering

and leaving the room. As for neupogen, I havent yet encountered a patient

who has an allergic reaction.

LaurynRN · Jun 5, 2006

I wanted to answer the question regarding evidenced based practice and caring for the neutropenic patient. The answer is that there isn't an answer. There is no evidence that limiting diet in any way prevents infection! There are many reasons, one reason is that it is very hard to conduct a study with the same variables, another is that people just assume that the reasoning for no fresh fruits and veggies just "makes sense". Every article or study found reports at the end that there was no significant difference in those who restricted diet as compared to those who were restricted. And each states that furthur research is needed.

I recently researched this topic in an attempt to change things on my unit....I searched for about 15 weeks and wrote a paper on my findings.