SARASOTA MEMORIAL HOSPITAL TITLE: NURSING PROCEDURE DATE: REVIEWED: PAGES: 11/85 11/17 1 of 4 PS1094 ISSUED FOR: Nursing RESPONSIBILITY: RN, LPN PURPOSE: OBJECTIVE: The purpose of this procedure is to protect the patient with a low neutrophil count from infection. The nursing staff will implement precautions to prevent infection in the neutropenic patient. DEFINITION: 1. Neutrophil: White blood cells responsible for recognizing and initiating the fight against infection. Also known as granulocytes. 2. Absolute Neutrophil Count (ANC): number of immature and mature neutrophils circulating in the blood. As a neutrophil matures, the nucleus appears to segment into lobes. Immature neutrophils are called bands because their nucleus appears as one lobe, or band. Mature neutrophils are called segs because their nucleus appears to have multiple lobes, or segments. If the ANC is not reported in the laboratory values, the following formula is used to calculate the ANC: ANC = WBC (white blood cells) value X [% of segs (mature polysegmented neutrophils) + % of bands (immature neutrophils ] EXAMPLE: WBC: 3.6 10x3/uL Segs: 44% (0.44) Bands: 10% (0.10) ANC = 3.6 X (0.44 + 0.10) = 3.6 X 0.54 = 1.9 3. Neutropenia: decrease in the number of circulating neutrophils in the blood as evidenced by an ANC less than lower limit of normal. Profound neutropenia is an ANC less than 0.5 10x3/uL Kurtin, 2016).Febrile neutropenia is an ANC < 1.0 10x3/uL and a single temperature of >38.3 o C (101 o F) or a sustained
PAGE: 2 of 5 temperature > 38 o C (100.4 o F) for more than one hour. 4. Nadir: Time of lowest blood cell count. For example, when the neutrophil count drops to the lowest after administration of chemotherapy. KNOWLEDGE BASE: 1. When the ANC drops below 1.0 10x3/uL, the patient is highly susceptible to infection and is without competent cells to fight infection. 2. Chemotherapy induced neutropenia (CIN) occurs when chemotherapy kills rapidly dividing cells. In this case, healthy bone marrow cells are being killed or altered. 3. Neutropenia may also occur with leukemia. In this case, immature white cells fail to mature and become competent at fighting infection. 4. Radiation therapy also can cause neutropenia by destroying mature white cells. PATIENT EDUCATION: 1. The patient should be educated regarding neutropenia precautions during the hospital stay and before discharge. Many chemotherapy patients may be at home when this nadir occurs. 2. Provide appropriate patient education sheets available in Staywell: a. Neutropenia Updated SMH b. Neutropenia (Updated) from Chemotherapy (SMH) c. Neutropenic (Updated) Precautions SMH d. Neutropenic (Updated) Diet (SMH) EQUIPMENT: PROCEDURE: Assemble the following: 1. Neutropenia Precautions sign (provided by Central Services through Neutropenia Precautions order) 2. Masks The following precautions will be initiated when the patient s ANC is less than or equal to 1.0 10x3/uL: 1. Verify Neutropenia Precautions order is present. This
PAGE: 3 of 5 order set includes an order for a private room Medical Necessity. Place patient in a private room. 2. Place the Neutropenia Precautions sign by the door. 3. Enforce good hand hygiene among personnel and visitors. 4. Ensure patient bathes daily paying meticulous attention to oral and perineal hygiene. 5. The patient will wear a mask when walking in the hall or going to another department for a procedure. 6. Allow no visitors or personnel with colds, upper respiratory tract infections, oral cold sores, or other contagious illnesses (e.g., chicken pox, herpes zoster, influenza) in the patient s room. If the visitor has a cold or mouth sore and insists on entering, the visitor will wear a mask while in the presence of the patient. 7. Allow no fresh flowers or plants in the room. 8. Change water in pitcher, denture cup and nebulizers daily. 9. Use aseptic technique when performing invasive procedures. 10. Do not administer intramuscular injections unless absolutely necessary. 11. Avoid enemas, rectal tubes, rectal temperatures, and rectal suppositories unless absolutely necessary. 12. Avoid urinary catheterization unless absolutely necessary. 13. Notify the physician of any temperature greater than or equal to101 degrees F or a sustained temperature of 100.4 degrees F for more than 1 hour Chart all temperatures in the electronic medical record. Notify the physician if chills occur. 14. Instruct patient to report chills immediately.
PAGE: 4 of 5 15. Prevent trauma to patient s skin and mucous membranes. Use an electric razor instead of a safety razor to prevent skin injury. 16. Prevent pressure sores and constipation. 17. Cleanse and protect wounds as directed. 18. Obtain an order to culture any draining wounds. 19. Educate the patient about protective measures (see Staywell patient education). SPECIAL NOTES: 1. Remember to immediately report to the physician any signs or symptoms of infection, no matter how insignificant they seem. 2. Wounds may not show drainage, i.e., pus, due to the low granulocyte count. Slight redness or swelling should be reported. DOCUMENTATION: Assessment/Reassessment Flowsheet: Document any early signs of infection, notification of the physician, nursing measures initiated, patient responses and any other information pertinent to patient s status. Select Neutropenic in Isolation Type row of flowsheet. Education Flowsheet: Document handout(s) provided in Isolation Type row. REFERENCE: Yarbro, C.H., Wujcik, D., & Gobel, B. H. (2011). Cancer Nursing: Principles and Practice (7th edition). Boston, MA: Jones & Bartlett Publishers. National Cancer Institute. (2010) Common Terminology Criteria for Adverse Events. Version 4.03. Bethesda, MD: US Department of Health and Human Services. Kurtin, Susan. (2016) Alterations in Hematologic and Immune Function in Core Curriculum for Oncology Nursing, 5 th Ed. (Itano, J., Ed). Pittsburgh: Oncology Nursing Society
PAGE: 5 of 5 REVIEWING AUTHOR (S): Deena Damsky Dell MSN, CNS, AOCN, RN-BC, LNC Barbara Poropat BSN, RN,OCN,NPD, Oncology APPROVAL: Clinical Practice Council 11/2/17