Your Patient is Neutropenic - Now What?

Ashley Hay, BSN, RN, BSN, RN

Neutrophils are a type of white blood cell needed for fighting infection, especially bacteria. While many ranges can sometimes differ slightly with certain laboratories, generally a normal count is considered between 1,500-8,000. Neutropenia can be classified from mild to severe. The risk of infection increases greatly once the ANC falls below 500.

Determining the absolute neutrophil count serves to uncover how many of the total white blood cells (WBC) are neutrophils. This can be accomplished by a few different formulas, and example of which includes:

ANC = [(% segmented neutrophils + Bands) + (WBC)] / 100
(Neutrophilcount.com, 2017)

Causes

Neutrophils are produced inside the bone marrow, therefore causes of neutropenia can be linked to an issue in bone marrow production or destruction. Some examples include:

Chemotherapy & Radiation: destroys healthy blood cells & can cause marrow failure
Medication: especially those that suppress the immune system and some antibiotics
Leukemias: cancer directly affecting blood cells and bone marrow
Congenital: some infants are born with issues making neutrophils
Viruses and infections: including Hepatitis, HIV/AIDS, sepsis
Autoimmune disorders: the immune system attacks or destroys its own supply
Idiopathic: cause unknown, however same precautions will apply

Symptoms to Report

While neutropenia itself may not present with any identifiable symptoms, it is important to educate patients on what to watch for at home, specifically signs of infection.

Fever: patients should be checking their temperature twice a day and reporting any increase above 100.5 (some clinicians are comfortable waiting until 101). It is important to catch these fevers early
Mouth Sores: a low white count can sometimes lead to ulcerations in the GI tract. Patients should be educated to report sore throat, mouth sores or diarrhea. Rinsing with a Sodium Bicarbonate rinse (Mix 1 bottle of water with 1 tsp salt and 1 tsp baking soda - pour into small cup, swish & spit 3x/day) can heal and help prevent a potential source of infection

Neutropenic Precautions

These patients are at increased risk of infection due to depression of their neutrophils. Prevention is key! These measures should be taken into consideration for your nursing care and patient/family education.

Frequent Handwashing: Handwashing, handwashing, handwashing! This point cannot be stressed enough. It is the best way to prevent the spread of infection for both the patient and anyone living in their home. Educate them on proper technique to ensure best results.
Avoid Crowded Places: More people equals more germs and opportunities for infection in a high risk patient. They don't have to miss out on a big event but limiting their outings to special occasions may be beneficial. Use of a face mask may also be necessary, depending on their counts.
Avoid Those Who Are Ill: If there is an ill relative (cough, cold or any other questionable symptoms) they should save their visit for another time. Keeping distance from anyone who is under the weather is best practice and can prevent problematic infections.
Food Safety: Nutrition is a major component in helping the body recover from any illness. However, many nutritious foods such as rare/raw meats, undercooked eggs, and fresh fruits/vegetables can have bacteria present that can be harmful to a immunocompromised patient. Education on how to properly clean and/or cook these foods can help to decrease the risk.

Neutropenic Isolation

In some cases (for example, transplant) the patients are so immunocompromised they may need more protective measures, like isolation. In this type of strict isolation there are a few points to keep in mind.

No Fruit: For the reasons discussed above, the patient will have dietary restrictions including no fruit and everything must be fully cooked.
No Flowers: Fresh flowers can also carry potentially harmful bacteria for these patients. Guests may have good intentions by sending or bringing this gift to the hospital, but will unfortunately have to be turned away. Explaining reasons why it is in the best interest of the patients safety can help guests and family better understand.
Cover Up: All visitors, clinicians and staff must wash hands, wear a gown, face mask and gloves before entering the room - decreasing any risk of bringing in outside pathogens. Shoe bootie covers may also be required.

Conclusion

With all of these restrictions and precautions in place this can be a frustrating time for your patient - especially if they are young. It's usually quite difficult to ensure mask compliance in a toddler or confine them to a hospital isolation room for days. Making sure the patient and family have a few activities can be a helpful distraction for any age. Reinforcing the importance of infection prevention can lead to better patient outcomes. Educating the patient, family and visitors is a priority in this population. With your guidance they can decrease the overall risk of contracting life threatening infections and be as protected as possible.

References:

Neutropenia: Causes, diagnosis, and treatment

Neutropenia - Mayo Clinic

Neutropenia - WebMD

Neutrophil Count

spotangel, DNP, RN, NP · Jul 27, 2017

Thank you Ashley! You got me with that fresh flowers and fruit bit!

Annerw · Jul 27, 2017

Sadly 4 weeks ago my husband passed away from AML and he had severe Neutropenia for several months leading up to his death. He was in a Haemotology Ward , but we found the only time they gowned and masked etc was when they were doing chemo, I guess maybe being a specialized ward it was different . I used to cook all his meals at home and bring them in, we had strict guidelines and I installed a fridge in my car to keep the food the way I was told. My only concern I had was the hand washing and as a Palliative Care Nurse I was forever on the nurses backs to wash their hands. My other issue was, even though he was in Neutropenic Precautions, sometimes his bed wouldn't get changed for many days, so that was always my first job when I got in to visit every day.

smf0903 · Jul 28, 2017

Sadly 4 weeks ago my husband passed away from AML and he had severe Neutropenia for several months leading up to his death. He was in a Haemotology Ward , but we found the only time they gowned and masked etc was when they were doing chemo, I guess maybe being a specialized ward it was different . I used to cook all his meals at home and bring them in, we had strict guidelines and I installed a fridge in my car to keep the food the way I was told. My only concern I had was the hand washing and as a Palliative Care Nurse I was forever on the nurses backs to wash their hands. My other issue was, even though he was in Neutropenic Precautions, sometimes his bed wouldn't get changed for many days, so that was always my first job when I got in to visit every day.

I'm so sorry for your loss Annerw:(

spotangel, DNP, RN, NP · Jul 28, 2017

Hugs Annerw !

Ashley Hay, BSN, RN, BSN, RN · Jul 30, 2017

Sadly 4 weeks ago my husband passed away from AML and he had severe Neutropenia for several months leading up to his death. He was in a Haemotology Ward , but we found the only time they gowned and masked etc was when they were doing chemo, I guess maybe being a specialized ward it was different . I used to cook all his meals at home and bring them in, we had strict guidelines and I installed a fridge in my car to keep the food the way I was told. My only concern I had was the hand washing and as a Palliative Care Nurse I was forever on the nurses backs to wash their hands. My other issue was, even though he was in Neutropenic Precautions, sometimes his bed wouldn't get changed for many days, so that was always my first job when I got in to visit every day.

So sorry to hear of your loss

Your Patient is Neutropenic - Now What?

Causes

Symptoms to Report

Neutropenic Precautions

Neutropenic Isolation

Conclusion

About Ashley Hay, BSN, RN, BSN, RN

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