Care of a Neutropenic Patient by kimberly blythe

S.H. is a 66 year old woman diagnosed with Stage IIIB epithelial ovarian cancer. She has recently retired from her job as a dental office manager. She is a mother to two twin girls who are about to celebrate their eighteenth birthday. Her medical history includes hypertension, coronary artery disease and hyperlipidemia. Her only allergy is to penicillin which causes her to break out in hives. Her medications include: an over the counter multivitamin, lisinopril, amlodipine, and simvastin . She does have a family history of breast cancer with a maternal grandmother who died at the age of 55 from it. S.H. presents for her yearly physical with abdominal bloating, distention and a change in bowel function. Her physician orders an ultrasound, CA-125, CBC and does a through physical examination. The findings are as follows:

kimberblythe32 — 2016-07-20 11:49:13 UTC

(See chart to the right)

CBC w/o Diff:

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WBC 4.5
RBC 3.0
Hgb 9.0
Hct 30 %
Platelet 100
Chemistry:
Sodium 140
Potassium 3.5
Glucose 100
BUN 10
Creatinine 1.0
Cholesterol 140
Calcium 9.0
Lipase 10.0
Total Bilirubin 1.0
AST 10
ALT 15
CA 125 130
Pelvic Exam Findings:
Ovaries and cervix were palpated. Mass palpated on right and left ovaries.
Radiological Findings:
2.0 cm hyperechoic mass noted on right ovary. 1.5 cm hyperechoic mass noted on left ovary. Free fluid ascites appreciated in pelvis.

After discussing findings with S.H, her physician refers her to a gynecological oncologist where an explorative laparatomy, total abdominal hysterectomy with a bilateral salpingo-oopherectomy, and port placement is performed. The pathology came back two weeks later as Stage IIIB epithelial ovarian cancer.

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S.H. and her oncologist discuss the treatment plan for progression control and prolonged survival. They agreed on the need for adjuvant chemotherapy that will start in two more weeks (fours weeks after surgery). According to NCCN Guidelines (2015), the treatment will include paclitaxel 80 mg/m2 on days 1, 8, and 15 and carboplatin AUC 6 IV every three weeks for six cycles (See attached NCCN Guideline algorithm for ovarian cancer).

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Two weeks has passed and S.H. is coming in for Cycle 1 of paclitaxel/ carboplatin. Her height is 172.7 cm and her weight is 76.2 kg. Her baseline CBC lab values are: WBC of 6.5; Hgb of 12.5; Platelet count of 125k; and Absolute Neutrophil Count (ANC) of 2,100. S.H. received pre-medications to prevent hypersensitivity reactions and tolerated both infusions well. S.H. calls the clinic ten days later reporting flu-like weakness, a fever of 101 F, and no appetite. The nurse suspects febrile neutropenia and asks her to come into the clinic immediately to be seen by the physician.

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Question 1:

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Question 1:

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What are the risk factors for febrile neutropenia that S.H. possesses? (Reference Neutropenic Sepsis and NeutropeniaDocuments)

Question 2:

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Using the above article, what signs and symptoms would the nurse be looking for with S.H. for febrile neutropenia (Reference neutropeniadocuments) ?

S.H. is brought in and her vital signs are: Temp. 103 F, B/P. 90/40, HR. 128, O2. 96 %. The CBC results are as follows:

kimberblythe32 — 2016-07-20 18:47:19 UTC

WBC 0.54
RBC 3.0
Hgb 7.5
Hct 27.5
Platelet 56
Absolute Neutrophil Count 0.42 or 420
The nurse sees that S.H. is experiencing febrile neutropenia and consults with MD to have her directly admitted to the partnering inpatient oncology unit at the hospital. The nurse receiving S.H. is familiar with caring for neutropenic patients and her hospital's policy on neutropenic precautions.

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Question 3:

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Using the attached Neutropenicprecautionspolicy, what educational points will S.H.'s nurse go over with her in regards to neutropenic precautions?

The oncologist consults the local infectious disease doctor. The infectious disease doctor is very familiar in caring for neutropenic oncology patients.

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See the attached document careofneutropenicpatients.

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Question 4:

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Using attached careofneutropenicpatients, what tests, radiologic examinations and medications will he order for S.H.?

The two sets of blood cultures were positive for pseudomonas, urinalysis and UA are negative, and chest xray shows bilateral infiltrates indicative of pneumonia. She is started on cefepime and vancomycin IV.

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Question 5:

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What is the role of colony stimulating factors or CSF for S.H.?

Question 6: After one week on IV antibiotics and the CSF neupogen, S.H.'s lab values are as follows:

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WBC 2.4
RBC 3.2
Hgb 10.0
Hct 30.0
Platelets 105
Absolute Neutrophil Count 1.6 or 1600

She has been afebrile and her vital signs are within normal limits. Her infectious disease doctor will transition her to oral antibiotics today and will prepare her for discharge tomorrow. What necessary education will the nurse give S.H. before discharge about staying safe while her counts are continuing to bounce back.

Clinical Pearls:

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**Febrile neutropenia can be defined as a single temperature of 38.3°C or more orally or 38.0°C or more over one hour and a total neutrophil count of less than 500 neutrophils/mcl or less than 1,000 neutrophils/mcl and a predicted decline to less than 500 mcl over the next 48 hours.

Although fever in healthy individuals does not necessarily indicate severe illness, fever in patients with neutropenia may herald a life-threatening infection
The risk of clinically significant infection is higher in those with a prolonged duration of neutropenia (more than 7 days)
Why this matters……
70-75% of deaths in acute leukemia are directly r/t infection secondary to neutropenia
50% of deaths in solid tumors are…
Absolute Neutrophil Count (ANC) – a measure that represents the number of mature WBC’s in

circulation. It is derived by multiplying the WBC count with the percent of neutrophils (Polys +

bands). ANC = WBC X % neutrophils (polys + bands)
Neutropenia- The condition where there is a marked decrease in circulating neutrophils.
Grade 1 < LLN–1,500/mm3
Grade 2 < 1,500–1,000/mm3
Grade 3 < 1,000–500/mm3 Febrile neutropenia present**
Grade 4 < 500/mm3 (Life-threatening consequences, e.g., septic )
Grade 5 Death
Why are oncology patients so susceptible to neutropenia?
Treatments, radiation & CHEMOTHERAPY

Myelosuppression: The bone marrow is the manufacturing center of blood cells and the suppression of bone marrow activity causes a deficiency of blood cells. Many chemotherapy treatments (and some cancers) can disrupt this manufacturing center, leaving the patient without an adequate supply of any combination of, or all of the white blood cells, red blood corpuscles, and/or platelets. The result can lead to an increased susceptibility to infection, anemia and a risk for bleeding.
Who is at risk?
Chemotherapy that causes myelosuppression
Cancer in the bone marrow itself
Immune system dysfunction
Malnutrition
Those receiving combination therapies
Those on long term treatment (the degree and duration of neutropenia is a factor in risk for infection).
- Short-term < 10 days
- Long-term > 10 days
Lifespan of a Neutrophil:
- 10-14 days for bone marrow to produce
- Once released into circulation live only 4-8 hours.
- Lifespan so short, continuous production in the bone marrow necessary for healthy counts-when disruption occurs, quickly affected.

What is Nadir-as it related to chemotherapy?

Nadir- Following cytotoxic therapy, the time or level at which the lowest blood cell count is reached.

Usually 7 – 10 days after treatment.

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