Med-Surg Immune System, part 11: Neutropenia, Anemia, Thrombocytopenia

by Cathy Parkes October 08, 2020

Neutropenia, anemia, and thrombocytopenia are common complications associated with cancer and cancer treatment. In this article, we cover the definitions and lab values associated with these conditions, as well as some important nursing care and patient teaching tips you need to know.

These conditions and their nursing precautions and patient teachings are covered in our Medical-Surgical flashcards (Immune system), and Cathy’s videos follow along with the cards.

Neutropenia

Neutropenia is a condition marked by insufficient numbers of neutrophils. Neutrophils are the most common of the five types of white blood cells and their approximate normal range is between 2,500 - 8,000/mm³.

When a patient has a low white blood cell count, their immune system is at risk.

The approximate normal range for neutrophils is between 2,500 - 8,000/mm³. Neutrophil counts below 2500/mm³ can indicate neutropenia.

Neutropenic nursing care and hospital precautions

You may be familiar with contact precautions in a hospital setting. Contact isolation usually occurs when a patient has a high-risk communicable disease (e.g., MRSA) and healthcare professionals must don protective clothing and gear to protect themselves from contracting the disease from the patient.

Neutropenic precautions, or the precautions taken when you have a patient with neutropenia, are essentially the opposite. Neutropenic precautions require healthcare professionals to don protective clothing and gear to protect the vulnerable, immunocompromised patient. The imperative is to ensure that this patient does not become sick.

Nursing care

In addition to neutropenic precautions, if you have a patient with neutropenia, you will also follow other important nursing care steps.

Carefully monitor the patient’s temperature. It’s important if they have a fever to act fast.

Restrict visitors who are ill, because there is a greater risk that this patient could contract an illness from them than from a healthy visitor.

Do not keep any fresh plants or fresh flowers in the patient's room, as they can contain potentially dangerous microorganisms.

Keep dedicated equipment, like a vital signs monitor, in this patient’s room. You do not want the equipment roaming from room to room and possibly infecting the patient.

Medications for neutropenia

The medication for neutropenia is called filgrastim. Filgrastim works by causing bone marrow to increase the production of neutrophils. Filgrastim is one of the key medications covered in our Pharmacology Flashcards for Nursing Students.

Neutropenia patient teaching

A patient with neutropenia will need some specific instruction before they are discharged, including:

  • Take their temperature daily and report any temperature greater than 100° to their provider.
  • Avoid crowds
  • Avoid sick people
  • Do not consume raw foods. Raw foods carry a greater risk because the bacteria or contaminants have not had a chance to be killed off in the cooking process.
  • Avoid yard work or gardening. This is the same principle as disallowing flowers and plants in the patient’s hospital room, as plants may contain dangerous microorganisms.
  • Avoid changing the cat litter box, as this is a very bacteria-filled area of the home.
  • Wash their dishes in hot water or in the dishwasher so the dishes can be sterilized.
  • Wash their toothbrush in the dishwasher daily, or use a bleach solution. This helps ensure the toothbrush stays as clean as possible.

Anemia

Anemia, a condition marked by decreased red blood cell counts, is another common side effect with cancer treatments like chemotherapy and radiation.

Normal red blood cell count is between 4.2 - 5.4 million/uL for women and 4.7 - 6.1 million/uL for men. Red blood cell counts lower than those ranges can indicate anemia.

You may hear anemia used synonymously with “low iron,” but they are not exactly synonymous. Anemia just means low red blood cell counts, and one common type of anemia is iron-deficiency anemia, which can be checked by measuring actual iron levels, and/or by measuring the hemoglobin levels in the blood (which is not the same as the iron levels in the blood, but it is used as a proxy measure for iron).

Normal hemoglobin levels for women are between 12 - 16 g/dL and for men, 14-18 g/dL. Low levels of hemoglobin can indicate anemia.

Both red blood cells and hemoglobin lab value ranges are covered in our Lab Values flashcards for nursing students.

Medications

The medication given for anemia is called epoetin alfa, which works by stimulating bone marrow to increase the production of red blood cells and is very similar to the natural substance in your body (erythropoietin) that prevents anemia.

Another supplement that can help anemia is ferrous sulfate, which is an iron supplement. Iron is an essential component needed for hemoglobin, and iron helps the body to make healthy red blood cells.

Patient teaching for anemia

A patient with anemia should receive some specific instructions for their condition.

  • Increase their intake of foods high in iron folate and B12 (leafy green vegetables, nuts, red meat, fish).
  • Take extra rest periods and practice patience—anemia can cause dramatic fatigue.

Thrombocytopenia

Thrombocytopenia, a condition marked by decreased platelet counts, is another common side effect of chemotherapy. Because platelets help the blood to clot, the lack of platelets seen with thrombocytopenia puts a patient at a very high risk for bleeding.

The expected range for platelets is between 150,000 - 400,000 mm³, and levels lower than that can indicate thrombocytopenia.

Nursing care

There are several nursing care practices and precautions to remember if you have a patient with thrombocytopenia.

Monitor for blood in the patient’s stool, urine, or vomit. Internal bleeding is never a good thing, but it is especially risky for these patients.

Avoid IVs and injections whenever possible, because these are opportunities to bleed. When it is not possible to avoid IVs and injections on a patient with thrombocytopenia because a blood draw or injection is required, hold prolonged pressure over the area to ensure that the patient stops bleeding.

Implement falling safety precautions in this patient’s room, because if this patient falls and starts bleeding, it has the potential to be fatal.

Patient teaching

A patient with thrombocytopenia will need to receive some specific patient teaching and instruction to reduce the bleeding risks associated with their condition. These important patient teaching tips include:

  • Use a soft toothbrush. A hard toothbrush can poke holes in gums and cause bleeding.
  • Avoid blowing their nose vigorously, which could lead to a ruptured blood vessel.
  • Avoid taking NSAIDs, like ibuprofen, because they carry a risk of GI bleeding, which is particularly dangerous for this patient.
  • Avoid falling whenever possible. Patients do not normally try to fall, of course, but if they are instructed to avoid activities that could lead to falling because they could have fatal bleeding, then that will help them know to avoid activities like walking on ice or frost, wearing low tread shoes, or reaching for something in a risky way.

Cathy’s teaching on cancer treatment and complications is intended to help prepare you for Medical-Surgical nursing exams. The Medical-Surgical Nursing video series is intended to help RN and PN nursing students study for nursing school exams, including the ATI, HESI and NCLEX.


Full Transcript

Alright. In this video, we are going to continue our coverage of common complications associated with cancer treatment and chemotherapy. Specifically in this video, we are going to talk about neutropenia, anemia, and thrombocytopenia.

So with neutropenia, neutropenia means we have insufficient numbers of neutrophils. So our patient's white blood cell count is down and they are at higher risk for infection.

So we need to implement neutropenic precautions at the hospital. So this is basically like reverse isolation. So instead of putting on protective gear to go in a patient's room to protect you from exposure, you're putting on that protective gear to help prevent exposure for the patient, right? We want to really make sure they don't get sick.

So in addition to neutropenic precautions, we're going to want to carefully monitor our patient's temperature.

We're going to restrict any visitors who are ill.

We want to not allow any fresh plants or flowers in the patient's room.

And we want to keep dedicated equipment in the patient's room, as well. So you want to keep a vital signs machine there in the patient's room. We don't want a vital signs machine kind of roaming from room to room and possibly contaminating the patient.

We can also give the patient a medication called filgrastim. So filgrastim helps to boost up the patient's neutrophil count. So the way I remember this medication and the cool chicken hint that's on our pharmacology cards is that filgrastim will help the patient "fill up" on neutrophils. So hopefully, that will help you remember that medication as well.

Patient teaching. When the patient does home, they need to take their temperature daily and definitely report any temperature above 100 degrees to their provider.

They should avoid crowds, avoid sick people.

They should not consume raw foods.

They should avoid yard work or gardening.

They should not change their cat litter box and they need to make sure they wash their dishes in hot water or use a dishwasher.

They should wash their toothbrush as well in the dishwasher daily or use a bleach solution to make sure that stays as clean as possible.

In addition to neutropenia, anemia is another common side effect with cancer treatment. This is where we have decreased red blood cell counts.

So medications we can provide to help with this condition include epoetin alfa, which helps to increase red blood cell count.

In addition, we're gonna want to provide ferrous sulfate, which is an iron supplement, because iron is a key component of red blood cells.

In terms of patient teaching, we're going to want to encourage the patient to increase increase their intake of foods that are high in iron folate and B12.

We also want to encourage them to take extra rest periods because anemia can make you feel very, very fatigued. So the patient needs to give themselves some grace and patience and just take those extra rest periods.

Another key side effect with chemotherapy and cancer treatment is thrombocytopenia. This is where we have decreased platelet counts. And that places the patient at high risk for bleeding.

So we are going to want to monitor for blood in the patient's stool, urine, and vomit.

We are going to avoid IVs and injections whenever possible. When it is not possible, and we do have to do a blood draw or some kind of injection, we want to make sure we hold prolonged pressure over the area to ensure the patient stops bleeding.

And then in terms of patient teaching, we want to encourage the patient to use an electric razor versus a straight razor.

They should use a soft toothbrush.

They should avoid blowing their nose vigorously.

They should avoid NSAIDs as well such as ibuprofen because those medications carry a side effect of GI bleeding, and we definitely do not need that.

And then, the patient should avoid falling whenever possible, so implement safety precautions because if the patient were to fall, they are at higher risk for bleeding, and this could potentially be fatal.

Okay. So that is it for this video. When we come back, we will get into specific types of cancer starting with skin cancer. Hopefully, this video has been helpful. If it has, be sure to like the video and subscribe to our channel. And thank you so much for watching!


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