Question

CASE STUDY PROGRESS

M.D. has now completed three cycles of chemotherpy, with her last treatment 12 days ago. She comes to the emergency department with a 1-day history of fever, chills, and shortness of breath. On arrival, she is slightly confused and agitated. Vital signs are 100/60, 119, 26, 103.6° F (39.8° C), Spo₂ 86% on room air. The chest x-ray examination shows diffuse infiltrates in the left lower lung consistent with pneumonia. Her basic metabolic panel is within normal limits, except the blood urea nitrogen (BUN) 28 mg/dL (10.0 mmol/L) and creatinine 1.6 mg/dL (141 mcmol/L).

Chart View

Complete Blood Count

White blood cells (WBCs)	1200/mm3 (1.2 x 109/L)
Neutrophils	34%
Segmented (“polys”)	30%
Bands	4%
Lymphocytes	60%
Monocytes	3%
Eosinophils and basophils	2%
Hematocrit (Hct)	24.9%
Hemoglobin (Hgb)	8.7 g/dL (87 g/L)
Platelets	85,000/mm3 (85 x 109/L)

16. Interpret M.D.’s laboratory results and explain the reason for any abnormal results.

17. M.D.’s absolute neutrophil count (ANC) is calculated as less than 500/mm3, describe the significance of this value.

18. What is your nursing priority at this time?

19. What is the single most important nursing intervention for a patient with an ANC below 500/mm³?

20. When is neutropenia most likely to occur in a person receiving chemotherapy?

21. What type of isolation do you need to initiate for M.D.? Outline the guidelines for maintaining this type of isolation.

22. What collaborative care interventions do you expect for M.D.?

23. What immediate nursing interventions do you need to take?

24. What actions do you need to take because M.D. had a left axillary lymph node dissection and why?

25. The provider orders a 500-mL normal saline bolus now, with orders to infuse over 2 hours. You decide to use M.D.’s implanted port for IV access. After you access the port and connect the fluid, the infusion pump alarms that the line is occluded. What will you do?

Answer 1

16)MD' laboratory results suggests the following:

* Leukopenia- low WBC level - patient's receiving chemotherapy usually has low WBC levels and they are more prone to get infections.

* Anaemia- She has low Heamoglobin levels.

* Low Hct level- It can be due to insufficient supply of RBC due to Anemia.

* Thrombocytopenia- low platelet levels. Patient's with cancer has higher chance to get thrombocytopenia.

* Also she has higher BUN levels and creatinine level. It can be due to poor blood flow to kidney, indicating some kidney damage.

17) Normal level of Absolute Neutrophils Count(ANC ) for a healthy individual is 2500 - 6000 /mm3.

Here, MD's ANC is less than 500/mm3 which indicates Severe Neutropenia. It says that she has developed an infection.

18) The priority nursing care to be done is to Administration of oxygen to the patient. Since her spo2 is only 86 percent and has shortness of breath, first a nurse should administer oxygen via facemask to enhance proper breathing.

19) Prevention of infection-

The importance nursing intervention for a patient with low ANC is prevention of infection. A nurse has follows sterile technique while administering any medicines intravenously, should follow hand hygiene, teach patient about preventing infection, should follow standard precautions.

20) Neutropenia usually occurs 7 -12 days after receiving Chemotherapy. It may depend on the chemotherapy you receive. The drugs used in Chemotherapy kills the cancer cell as well as the normal cells, ie, why a patient develops neutropenia after chemotherapy.

21) Neutropenic isolation-

MD needs Neutropenic isolation. Neutropenic or protective isolation means the patient will be isolated in a separate room until the neutrophils level come to normal to prevent infections.

Guidelines for neutropenic isolation :

* Place notice on the door-

Place a notice Infront of the door which says to follow standard precautions before entering the room.

* Handwashing-

The healthcare professional has to do handwashing before entering the room and after leaving the room to prevent infection.

* Provide neutropenic diet-

A patient with neutropenia has to take neutropenic diet- or, diet with low microbes. She cannot take raw food items or uncooked meats etc.. Hospital staff should ensure that she receives neutropenic diet.

* Patient should have separate equipments like thermometer etc. Equipments used for another patient should not be used for her.

22) Interventions for MD includes the following:

* Administering oxygen to enhance proper breathing.

* Administering Antipyretics to reduce hyperthermia.

* Administering IV fluids to avoid dehydration and enhance proper blood flow.

* Administering Antibiotics to prevent infection.

* Continous monitoring of vital signs.

23) Immediate Nursing intervention include Administering oxygen. Since, the patient had shortness of breath and spo2- 86percent, it important to administer oxygen first. Otherwise, the patient develop respiratory distress.

24) Sterile surgical dressing should be done at the surgical site to prevent the entry of bacteria thereby preventing infection.

Also, patient should be monitored for any signs of bleeding from the surgical site as her platelet count is low and she is more prone to have bleeding.

25) If the line is occluded, I will immediately stop the infusion and start a peripheral IV access and will administer the IV fluids through that.

( Note: donot flush the port with heparin flush if it is occluded as it can result in bleeding since her platelets are low. So it is advised to start a new IV line)