Question regarding neutropenic patient...

[AmyRN1227]

Hi all,

I'm PRN at two places, both oncology/med surg floors. Well, I worked last nite, had an awful nite. I had a 43yr old pt that just got diagnosed with lung cancer with mets to brain, liver, and bone. Then I had two surgicals that nothing was done on, had to get consents signed, do preps, and start the surgical checklist and then had a lady all the way down at the end of the hall who "accidently pulled her IV out because she hit her bedside table". Then I also had an IV left for me that was bad, wasn't even taken out, but didn't flush. Okay, so my lady who was neutropenic, the aide didn't get the second set of vitals until way late like maybe 9:30pm...told me in passing she had a 101.1 fever. Didn't even relate her being neutropenic so just gave her Tylenol for the fever. Luckily her fever came down. But got a call from my manager this afternoon stating the doctor had a fit because he wasn't called. That she could have gone septic and died. And at my other place, the standards are not the same. Well, we have eight or nine pts so if someone is running a fever, I relay it to the charge RN who then will call the doc. She's considered our desk nurse and does all the calling of the docs. Does anyone else feel like every little thing we do wrong is picked out, but we don't get appreciated for anything? Plus they had a "code review" this afternoon regarding a code that happened involving a 53yr old pt whose now a vegetable because the husband is really upset, saying we didn't respond quick enough. I think I'm getting burnt out and I've only been a nurse for THREE years. Now my manager wants me to come in and read the policy book on cancer pts, which will take about two hours so I know the policies at their place. Like I'm just a crappy nurse. I do feel bad. I'm glad the pt is okay. But I don't need phone calls at home regarding this stuff. :angryfire :angryfire

Amy

[julieK]

I can understand if the temp was something like 100.6 and you didn't report it b/c on other floors the policy is usually to report over 101. But with neutropenic pts, we report 100.4 and above. Any patient with >101 should have been reported, neutropenic or not.

Don't worry, though. It will make you a better nurse. I got my head handed to me yesterday because I didn't make blood slips for cultures (something that the clerk should have done but didn't and it is of course the RN's responsibility to follow up) so the cultures weren't done in a timely manner and the doc threw a fit.

-Julie

[stevierae]

I have a question about neutropenia. Shouldn't Neupogen (at least theoretically) build up neutrophils and PREVENT neutropenia? Isn't Neupogen given to most oncology patients for this very reason, or is its usage selective and limited?

[caroladybelle, BSN, RN]

I have a question about neutropenia. Shouldn't Neupogen (at least theoretically) build up neutrophils and PREVENT neutropenia? Isn't Neupogen given to most oncology patients for this very reason, or is its usage selective and limited?

Neupogen cannot be used in some Oncology patients for various reasons, or its use may have to be delayed for various reasons related to treatment.

For example, patients being treated for Leukemia either cannot use it or must have it's usage delayed. Cancer cells are fast growing/reproducing cells (leukemia/WBCs) =you give a drug that targets fast growing/reproducing cells (WBCs) to speed up = you trigger blast crisis (excess amounts of defective WBCs) = which frequently induces respiratory failure, among other problems. And you have basically undone the effects of the chemo in reducing the cancer and worsen the prognosis.

MDs carefully check the cellular specifics of Leukemias (and other CAs) to determine whether Neupogen can be used or when in the cycle that it may be used. Unfortunately, because of the nature of leukemia, the neutropenia is probably the most profound, and is one of the diseases that is least likely to be able to use Neupogen to treat it.

There are also financially constraints, in patients that have limited resources. Some have been known to refuse it for that reason. It can also cause bone pain, that is excruciating.

And ocasionally on solid tumors, the MD doesn't expect that profound a nadir, but the neutropenia occurs anyway and must be dealt with. Or an ommaya reservoir/chemo pump leaks and the patient receives more systemic effect than originally intended.

[stevierae]

Neupogen cannot be used in some Oncology patients for various reasons, or its use may have to be delayed for various reasons related to treatment.

For example, patients being treated for Leukemia either cannot use it or must have it's usage delayed. Cancer cells are fast growing/reproducing cells (leukemia/WBCs) =you give a drug that targets fast growing/reproducing cells (WBCs) to speed up = you trigger blast crisis (excess amounts of defective WBCs) = which frequently induces respiratory failure, among other problems. And you have basically undone the effects of the chemo in reducing the cancer and worsen the prognosis.

MDs carefully check the cellular specifics of Leukemias (and other CAs) to determine whether Neupogen can be used or when in the cycle that it may be used. Unfortunately, because of the nature of leukemia, the neutropenia is probably the most profound, and is one of the diseases that is least likely to be able to use Neupogen to treat it.

There are also financially constraints, in patients that have limited resources. Some have been known to refuse it for that reason. It can also cause bone pain, that is excruciating.

And ocasionally on solid tumors, the MD doesn't expect that profound a nadir, but the neutropenia occurs anyway and must be dealt with. Or an ommaya reservoir/chemo pump leaks and the patient receives more systemic effect than originally intended.

Thank you, caroladybelle, for the excellent and detailed answer. I did not realize that Neupogen was that expensive...no wonder all the chemo patients at Apria got it...any way to make a buck (or many bucks) for the company--

[chris_at_lucas_RN, RN]

Was I really wrong not to call the doctor??? I'm trying to find out what everyone else's policy is regarding neutropenic pts. Because at my other place we wouldn't have called, just gave her the Tylenol and monitor her.

You were wrong not to know or at least suspect that your patient was neutropenic. Isn't that kind of a gimme with onco patients? Seems like that would have been at the top of your mental list.

It does sound like you had a heavy load that shift, but prioritizing rather demands that the emergent and potentially emergent stuff be at the top of the list.

It will get better. Read the policies, get more familiar with the "red lights" of the types of patients you care for.

Good luck.

[actioncat]

Live and learn the hard way.

I would think a 101 temp would be worthy of a second look a the patient's chart, however. Aren't there parameters written on the pt.'s orders indicating when a VS merits a call to the doc?

I don't think it is a bad idea to review the handbook if you are planning on being floated to this floor in the future.

[caroladybelle, BSN, RN]

Thank you, caroladybelle, for the excellent and detailed answer. I did not realize that Neupogen was that expensive...no wonder all the chemo patients at Apria got it...any way to make a buck (or many bucks) for the company--

All drugs that help increase blood cell production are pretty expensive. There is actually a drug that can increase platelet counts, but one will rarely see it given d/t expense and that many insurances will not cover it. So in Onco, we have some patients that have received so many platelet infusions, that they become sensitized, and must have HLA matched platelets.

[Ted]

Another old thread brought to life!

Neutropenic/pancytopenic patients need lots of close watching!

Ted

[Ted]

. . .we have some patients that have received so many platelet infusions, that they become sensitized, and must have HLA matched platelets.

And then there are patient that are refractory to the HLA platelets too! Your post reminded me of one gentleman who received high-grade HLA platelets like once a week. . . for a LONG time. . . before he died. I hadn't thought about this person in years!!! I hold a vivid picture of his face in my mind and recall him telling me how sick and tired he was of all of the blood transfusions. . . .

He was such a gentle person.

Ted