Basic Infection Prevention and Care of the Immunocompromised Patient

Question 1

Myelosuppression

Answer 1

refers to a process that disrupts these stem cells and, consequently, affects all of the different types of blood cells: red blood cells, white blood cells, and platelets. This condition manifests as a decrease in neutrophils, megakaryocytes, and erythrocytes in the bone marrow.

Myelosuppression is the most common dose-limiting toxicity of chemotherapy. Most chemotherapy agents cause some degree of myelosuppression. The severity depends on the agent’s mechanism of action and the overall treatment plan.

Question 2

Neutropenia

Answer 2

a significant reduction in the absolute number of circulating neutrophils in the blood. An absolute neutrophil count (ANC) of less than 1,500/mm3 defines neutropenia. The severity of a patient’s neutropenia is related to the relative risk for infection.

Mild: ANC less than the lower limit of normal to 1,500/mm3

Moderate: ANC less than 1,500/mm3 to 1,000/mm3

Severe: ANC less than 1,000/mm3 to 500/mm3
Life-threatening: ANC less than 500/mm3

Question 3

Anemia

Answer 3

is most commonly diagnosed and graded by tracking the patient’s hemoglobin level. A hemoglobin of 11g/dl or lower or 2g/dl or greater below baseline indicates anemia. Although hematocrit or red blood cell count can also be used to determine anemia, hemoglobin is most commonly used because it reflects physiologic consequences.

Question 4

Thrombocytopenia

Answer 4

is present when a patient’s platelet count is less than 140x10 / L.

Question 5

Nadir

Answer 5

A patient will most commonly experience a nadir 8-12 days after receiving cytotoxic therapy. Nadir is the term used to describe the time at which the blood counts reach their lowest level. Recovery occurs about 21-28 days after chemotherapy administration.

Question 6

cell cycle specific agents

Answer 6

Generally, cell cycle-specific agents are less damaging because they primarily affect the cell in a specific phase of the cell cycle.
Severe neutropenia can occur when cell cycle-specific agents are used in dose-intensification and combination regimens.
Example medications include antimetabolites.

Question 7

cell cycle nonspecific agents

Answer 7

Cell cycle-nonspecific agents cause more damage to stem cells because they affect the cell in all phases of the cell cycle.
The extent of neutropenia is dependent on the dose, schedule, and agent.
Some cell cycle-nonspecific agents (e.g., nitrosoureas) can cause delayed and prolonged neutropenia.
Nadir can occur at three to five weeks, with recovery ranging from one to two weeks to as many as to five to six weeks.
Example medications include alkylating agents and nitrosoureas.

Question 8

What puts a patient at higher risk for infection?

Answer 8

Advanced age; age of older than 65 years for chemotherapy-induced neutropenia (CIN)

Low neutrophil count at the start of treatment

Tumor involvement in bone marrow

Poor performance status

Renal dysfunction

Liver dysfunction

Previous myelosuppressive chemotherapy or radiation therapy

A history of severe neutropenia with similar chemotherapy

Preexisting infection, including open wounds or recent surgery

Hematologic malignancy and uncontrolled or advanced cancer (e.g., lung cancer has an increased risk of CIN)

Chemotherapy regimen (e.g., relative dose intensity of greater than 80%, dose-dense chemotherapy)

Use of specific medications, phenothiazines, diuretics, and immunosuppressive drug

Question 9

Signs and Symptoms of Infection

Answer 9

Neutropenic patients may lack the needed neutrophils to illicit an immune response and manifest classic signs of infection, such as redness, edema, and purulent discharge.

Fever greater than 100.4°F (38°C) is the most reliable sign or symptom of infection in patients with neutropenia. In many instances, neutropenic fevers are considered an emergency requiring immediate action.

Question 10

Febrile neutropenia

Answer 10

Defined as a one-time oral temperature greater than 101°F (38.3°C) or a temperature of 100.4°F (38°C) lasting for an hour. Febrile neutropenia occurs when ANC is less than 500/mm3 or less than 1,000 mm3 with an anticipated drop to 500/mm3 or less in the next 48 hours.

Question 11

What would indicate an infection of the GI tract

Answer 11

Abdominal pain, mucositis at any level of the digestive tract, and diarrhea

Question 12

What would indicate an infection of the genitourinary tract?

Answer 12

Dysuria, frequency, urgency, hematuria, cloudy urine, flank pain, perineal itching, and vaginal discharge

Question 13

What would indicate an infection of the head and neck

Answer 13

Swelling, itching, eye redness or drainage, ear pain or discharge, nasal congestion or drainage, oral ulcerations, and difficulty breathing

Question 14

What would indicate an infection of hematologic/immunologic

Answer 14

Decrease in diastolic BP, headache, oliguria, and flushed appearance

Question 15

What would indicate an infection of the CNS

Answer 15

Change in mental status, headache, seizure, vision changes, photosensitivity, nausea and lethargy

Question 16

What would indicate an infection of the respiratory tract

Answer 16

Cough, dyspnea on exertion, adventitious breath sounds, chest discomfort, asymmetric chest wall movement, and nasal flaring

Question 17

What would indicate an infection of indwelling devices

Answer 17

Erythema, pain or tenderness, edema, drainage and induration at site

Question 18

What would indicate an infection of dermatologic and mucous membranes

Answer 18

Erythema, tenderness, warm skin, edema, rashes, itching, skin lesions, and draining open wounds

Question 19

What would indicate an infection of

Question 20

Neutropenic diet

Answer 20

This is a diet restricting fresh fruit and vegetables, but there is little evidence to suggest this is effective in reducing infections in the neutropenic population.

However, safe food handling guidelines should always be followed. These include the following:

Thoroughly wash fresh fruit and vegetables.

Avoid uncooked and undercooked meats, seafoods, and eggs.

Ensure that proper hand hygiene is performed when prepping and preparing food.

Question 21

Prevention of Trauma to Skin and Mucous Membranes

Answer 21

It is important to try to prevent trauma to the patient’s skin and mucous membranes. To assist with this, nurses should do the following:

Provide meticulous care for all indwelling devices.

Prevent pressure ulcers.

Use a bowel regimen to prevent constipation that could result in straining and skin tears around the anus.

Change water in pitchers, denture cups, and nebulizers at least daily.

Consider the risks and benefits of invasive procedures.

Use only an electric razor to shave unwanted hair.

Protect the patient’s skin from cuts and burns. If a patient receives a cut or a burn, immediately cleanse and treat any wounds that break the skin.

Have patients use a soft-bristled toothbrush, which should be allowed to dry before storing.

Question 22

Vaccines

Answer 22

Influenza vaccines are recommended to be given at least two weeks before patients receive immunosuppressive or cytotoxic therapies. Influenza infections have been found to have substantial morbidity and mortality in patients with cancer. If a patient has undergone a hematopoietic stem cell transplantation, they will need to reinitiate a vaccine schedule according to provider and national (e.g., Centers for Disease Control and Prevention) recommendations. Patients should avoid receiving live attenuated vaccines.

Question 23

Nurses should ensure that the family understands how to best support the patient while at home. Equally, the patient needs to recognize how they can help to keep themselves healthy while at home. Some items to keep in mind include the following:

Answer 23

Report fever, chills, and other signs and symptoms of infection.

Maintain good personal hygiene by washing hands frequently with soap and water or antiseptic hand rub.

Patients should bathe daily.

Patients should avoid activities that may compromise skin integrity. If they choose to do such an activity, like gardening, they should wear gloves.

Patients or their caregivers should perform frequent oral assessment and care.

Patients or their caregivers should cleanse the perineal area from front to back after toileting.

People who are sick or showing signs of a contagious condition should be avoided.

Do not share food utensils.

Do not eat any food that has not been cooked or washed.

Adhere to safe food handling practices, and avoid consuming food when safety of preparation, storage, or serving is not guaranteed.

Do not provide direct care for pets or farm animals, and avoid contact with animal excreta.

Refrain from direct or indirect contact with reptiles, fish, and birds.

Avoid exposure to fresh or dried plants and flowers.

Do not enter, travel through, or stay in areas of construction or renovation, or where construction material or debris has been placed, or where a field has recently been plowed.

Consider vaccines for influenza, pneumonia, and other conditions as recommended by healthcare providers.

Avoid contact with people who have been vaccinated with a live vaccine within 30 days