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Chemotherapy-Induced Neutropenia Chemotherapy-Induced Neutropenia Elisabeth Sosa, MSN, ARNP, AOCNP Elisabeth Sosa is a certified adult oncology nurse practitioner. She practices within a large private-practice hematology/medical oncology group in Central Florida. She has previously been published in the Clinical Journal of Oncology Nursing (CJON). ABSTRACT Neutropenia is a common complication that occurs during treatment with chemotherapy in oncology patients. Some patients are at higher risk of developing neutropenia, based on type of cancer as well as type of treatment. Neutropenia can lead to serious complications, including infections and sepsis. Ensuring patient safety is important in decreasing morbidity and mortality. Neutropenia can be prevented and treated pharmacologically. Once patients are neutropenic, precautions should be taken to minimize risk of infection. These precautions increase patient safety during times of neutropenia. It is important that nurses have an understanding of neutropenia so that patients can be treated appropriately and complications can be avoided. Keywords: Oncology, Cancer, Neutropenia, Chemotherapy, Neutropenic fever, Neutropenic precautions, Infection, Myelosuppression nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 1 Continuing Nursing Education Course Director & Planners William A. Cook, PhD, Director, Douglas Lawrence, MA, Webmaster, Susan DePasquale, CGRN, MSN, Lead Nurse Planner Accreditation Statement NurseCe4Less.com is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. Credit Designation This educational activity is credited for 1.5 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity. Course Author & Planner Disclosure Policy Statements It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best practice in clinical education for all continuing nursing education (CNE) activities. All authors and course planners participating in the planning or implementation of a CNE activity are expected to disclose to course participants any relevant conflict of interest that may arise. Statement of Need Nurses are required to be knowledgeable about how neutropenia occurs, specifically in patients undergoing treatment with chemotherapy. The definition of neutropenia, as well as how to calculate the absolute neutrophil count (ANC) are essential to know when caring for individuals undergoing chemotherapy, in addition to the complications of neutropenia, including sepsis. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 2 Course Purpose This course will help nurses develop an understanding of the treatment of neutropenia specifically in patients receiving chemotherapy. Participants will also learn about neutropenic precautions in patients undergoing chemotherapy. Learning Objectives: 1. Define neutropenia (mild, moderate, severe) 2. Calculate the ANC (absolute neutrophil count) 3. Recognize patients who are most at-risk for developing neutropenia 4. Identify complications of neutropenia 5. Discuss two treatment options for neutropenia 6. Discuss various neutropenic precautions that patients should follow Target Audience: Advanced Practice Registered Nurses, Registered Nurses, Licensed Practical Nurses, and Associates Course Author & Director Disclosures: Elisabeth Sosa, MSN, ARNP, AOCNP, William S. Cook, PhD, Douglas Lawrence, MA, and Susan DePasquale, CGRN, MSN; all have no disclosures. Acknowledgement of Commercial Support: None exists. Activity Review Information: This has been peer reviewed by Susan DePasquale, CGRN, MSN. Review Date: April 21, 2014. Release Date: April 22, 2014 Termination Date: April 22, 2017 Please take time to complete the self-assessment Knowledge Questions before reading the article. Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 3 1. Calculate the ANC (absolute neutrophil count). WBC= 1.6, Neutrophil %= 12%, Lymphocyte %= 80%, Eosinphil %= 3%, Monocyte %= 5%. a. 1,280 b. 48 c. 272 d. 192 2. In the above question, what grade is the neutropenia? a. Grade 1 b. Grade 2 c. Grade 3 d. Grade 4 3. Which patient is at highest risk for developing neutropenia? a. 67-year-old male with acute leukemia undergoing high-dose combination chemotherapy. Has history of diabetes. b. 44-year-old female with breast cancer currently receiving single-agent Taxol. Has history of hypertension. c. 59-year-old male with prostate cancer receiving radiation to the prostate. Has history of COPD. d. 23-year-old female with Hodgkin’s lymphoma who is receiving combination chemotherapy. 4. All of the following are negative outcomes of neutropenia except: a. Increased costs b. Hospitalization c. Better response to chemotherapy d. Death nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 4 5. What should a chemo patient do if he/she has a fever of 100.6 degrees Fahrenheit? a. Stop checking his temperature b. Call his oncologist’s office and let them know c. Take antibiotics his wife has left over from when she had a UTI d. Call 911 6. You are a nurse in the emergency room caring for a patient who comes in with febrile neutropenia. You should do all of the following except: a. Draw blood cultures after starting IV antibiotics b. Collect urine for urinalysis and culture c. Ensure that a chest xray is ordered d. Ensure that IV antibiotics are ordered 7. Which foods should a patient avoid when he/she is neutropenic? a. Medium-rare steak b. Fresh apple with skin c. Golden corral buffet d. All of the above 8. You are caring for a neutropenic patient and reviewing neutropenic precautions. What advice is incorrect? a. Wash hands often, especially before you eat and after you use the bathroom. b. You are not allowed to touch your pet dog. c. You should stay away from gardening due to exposure to flowers, plants, and soil. d. Make sure you avoid crowds and stay away from sick people. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 5 9. What is the most common side effect of G-CSF (filgrastim, pegfilgrastim)? a. Bone pain b. Pain at the injection site c. Fever d. Fatigue 10. When is the best time to give G-CSF? a. The same day as chemotherapy so that the patient doesn’t have to come back b. 24 hours after chemotherapy c. When the patient is neutropenic d. The day before the next cycle of chemotherapy nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 6 Introduction The following case study is a common occurrence in patients receiving chemotherapy. The objective of this case study is to illustrate how patients commonly present after receiving chemotherapy and how treatment affects the neutrophil count. Suggestions will be made later on in the course on how to treat and prevent neutropenia. Case Study: Linda is a 62-year-old Hispanic female who was recently diagnosed with Stage III ovarian cancer. After undergoing TAHBSO (total abdominal hysterectomy bilateral salpingo-oopherectomy), the patient is referred to a medical oncologist to discuss treatment with chemotherapy. The oncologist recommends chemotherapy in the form of intravenous carboplatin and paclitaxel administered on day one every three weeks for six cycles. After discussing details of treatment, including risks, benefits, alternatives, and possible side effects, the patient agrees to proceed with chemotherapy. Linda returns to the infusion center for her first treatment. She tolerates treatment well, though she does experience fatigue and decreased appetite for about three days after chemotherapy. By Linda’s fourth cycle, she is feeling more fatigued and has lost about five pounds. Six days after she receives her fourth chemotherapy treatment, she notes a fever of 100.1 degrees Fahrenheit. She has fatigue and generalized weakness. Linda calls her oncologist’s office to report her symptoms and is instructed to come to the office immediately for further evaluation. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 7 Upon arrival, Linda has her blood drawn and vital signs measured. Her heart rate is 86 bpm, blood pressure is 119/61, and temperature is 99.9 degrees Fahrenheit. Her CBC (complete blood count) notes a WBC (white blood cell) of 1.1, ANC (absolute neutrophil count) of 400, hemoglobin of 11.9, and platelet count of 141,000. Chemotherapy And Neutropenia Chemotherapy plays an integral role in the treatment of patients with cancer. Neutropenia is the most common dose-limiting side effect of systemic chemotherapy. Neutropenia can lead to significant morbidity, mortality, and costs. For example, patients with febrile neutropenia may require hospitalization and broad-spectrum antibiotics (Camp- Sorrell, 2011; Crawford, Dale, & Lyman, 2004; Lyman, Lyman, & Agboola, 2005). Neutropenia Defined Neutrophils (also known as polymorphonuclear segmented cells or segs or polys) are a type of white blood cell. They are the body’s first line of defense against infection caused by viruses, bacteria, and other pathogens. Neutrophils make up the majority of white blood cells, usually between 45% and 75% (Cappozzo, 2004; Kurtin, 2012; Nirenberg et al., 2006). nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 8 Neutrophils are produced in the bone marrow.
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