THE FORUM المنتدى

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NEUTROPENIA

 Nursing Diagnosis and management of neutropenic patient:


Risk for infection secondary to impaired immunoincompetence due to:


 • Diminished neutrophil count secondary to bone marrow invasion or hypocellularity secondary to medications

 • Dysfunctional neutrophils (eg, secondary to myelodysplastic syndrome [MDS]

 • Dysfunctional or diminished lymphocytes

 • Hypogammaglobulinemia

 • Diminished immune response or anergy

 • Malnutrition

 • Surgery or invasive procedures

 • Antibiotic therapy (increased risk for superimposed infection)

 

– Neutropenic, infected patients often do not exhibit the classic signs of inflammation/ infection (ie, redness, cloudiness of any drainage); the only initial sign may be fever (and it often occurs later in the infectious process with neutropenia).

 

– Skin and mucous membranes are the body’s first line of defense against infection; loss of endothelial cell integrity allows organisms to enter the blood and lymph system.

 

Assessment


Patient


Assess the following areas thoroughly every shift or visit (with spot checks throughout shift if hospitalized) and notify physician of any signs of infection or worsening of status:


Skin: Check for tenderness, edema, breaks in skin integrity, moisture, drainage, lesions (especially under breasts, axillae, groin, skin folds, bony prominences, perineum); check all puncture sites (eg, intravenous sites) for signs and symptoms of inflammation/infection.


Oral mucosa: Check for moisture, lesions, color (check palate, tongue, buccal mucosa, gums, lips, oropharynx).


Respiratory: Check for presence of cough, sore throat; auscultate breath sounds.


Gastrointestinal: Check for abdominal discomfort/distention, nausea, change in bowel pattern; auscultate bowel sounds.


Genitourinary: Check for dysuria, urgency, frequency; check urine for color, clarity, and odor.


Neurologic: Check for complaints of headache, neck stiffness, visual disturbances; assess level of consciousness, orientation, behavior.


Temperature: Check every 4 hr or every visit; call primary health care provider if temperature is >38°C (>101°F), fever is unresponsive to acetaminophen, or patient shows a decline in hemodynamic status.

 

Diagnostic Studies


• Monitor complete blood count (CBC) and differential daily (especially absolute neutrophil count [ANC], lymphocyte count).


• Call physician if ANC is <1000, significantly different from previous count, or whenever patient becomes symptomatic (eg, febrile).


• Monitor globulin, albumin, total protein levels.


• Monitor all culture and sensitivity reports.


• Monitor radiology reports.

 

 Nursing Interventions


Environment and Staff


Thorough hand hygiene must be done by everyone before entering patient’s room each and every time. Allow no one with a cold or sore throat to care for the patient or to enter room, or come in contact with patient at home.


• Care for neutropenic patients before caring for other patients (as much as possible).


• Use private room for patient if ANC is <1000.


• Allow no fresh flowers (stagnant water).


• Change water in containers every shift (include O2 humidification systems every 24 hr).


• Ensure room is cleaned daily.

 

 Dietary


• Provide low microbial diet.


• Eliminate fresh salads and unpeeled fresh fruits or vegetables.

 

Patient


• Avoid suppositories, enemas, rectal temperatures.


• Practice deep breathing (with incentive spirometer) every 4 hr while awake.


• Ambulate; wear high-efficiency particulate air (HEPA) filter mask if neutropenia is severe.


• Prevent skin dryness with water-soluble lubricants, especially in high-risk areas (eg, lips, corners of mouth, elbows, feet, bony prominences).

 

Hygiene


• Provide meticulous total body hygiene daily (preferably with antimicrobial solution), including perineal care after every bowel movement.


• Provide thorough oral hygiene after meals and every 4 hr while awake; warm saline, or salt and soda solution, is effective; avoid use of lemon-glycerine swabs, commercial mouthwashes, and hydrogen peroxide.

 

Intravenous (IV) Therapy


• Do not use plastic cannulas for peripheral IVs when ANC is <500 (if possible per agency); a central vascular access device is preferred for long-term or intensive IV therapy.


• Inspect IV sites every shift; monitor closely for any discomfort; erythema may not be present.


• Maintain meticulous IV site care.


• Cleanse skin with antimicrobial solution before venipuncture (unless patient is allergic).


• Moisture-vapor–permeable dressings are permissible with strict adherence to institutional protocol.


• Change IV tubing per institution policy, using aseptic technique.


• Administer antimicrobial agents on time.

 

Expected Patient Outcomes


• Patient demonstrates an absence of infection as evidenced by an absence of fever, chills, inflammation, drainage, cough, dyspnea, sore throat, dysuria, or urinary frequency.

 • Patient demonstrates an absence of infection as evidenced by the presence of vital signs within normal limits, including intact neurologic status and intact skin.

 

Duration of Evaluation


Until patient is no longer neutropenic and any infection is resolved.