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HEMATOLOGIC FUNCTION

Sydne Mead-Smith BSN, RN, OCN

Seattle Cancer Care Alliance

Congratulations on pursuing OCN

Certification!

■ My story of certification

■ How certification can impact

you & your practice

Symptom Management: 22%

A. Etiology and patterns of symptoms (acute, chronic, late)

B. Toxicity and grading scales

C. Anatomical and surgical alterations

D. Complementary and integrative modalities (e.g. massage, acupuncture, herbal supplements)

E. Alterations in:

1. Hematologic function 8. Cardiovascular function

2. Immune function 9. Neurological function

3. Gastrointestinal function 10. Musculoskeletal function

4. Nutrition status 11. Comfort (e.g. pain)

5. Integumentary function

6. Genitourinary function

7. Respiratory function

Myelosuppression

■ Definition:

– Reduction in production & maturation of all blood cell lines

■ One of most common & potentially life-

threatening clinical complications experienced by patients with cancer

Shelton, B. In Holmes Gobel, B., et al eds. Advanced Oncology Nursing Certification: Review & Resource Manual. 2009: 405-442.

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Myelosuppression

■ Results in:

– Neutropenia and leukopenia,

– Thrombocytopenia

– Anemia

Shelton, B. In Holmes Gobel, B., et al eds. Advanced Oncology Nursing Certification: Review & Resource Manual. 2009: 405-442.

Platelets 7-8 Days

Neutrophil 7-12 Hours

Eosinophil 3-8 Hours

Basophil/mast cell 7-12 Hours

Monocyte/macrophage 3 Days

B Lymphocyte Type depend

T Lymphocyte Type depend

Erythrocyte 120 Days

Blood Cell Life Span in Blood

CIRCULATING BLOOD CELLS

LIFE SPAN

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Neutropenia

Decreased number of circulating neutrophils

Associated with increased risk of potentially life-threatening infection

Neutrophils 1st line of defense against bacterial

infection (localize & neutralize bacteria)

Normal rage (neutrophils)

2,500 to 6,000 cells/mm3

50% to 60% of total number of WBC’s

More than 50% of patients with neutropenia

can be expected to develop infection.

https://www.ons.org/practice-resources/pep/prevention-infection, accessed June 10, 2014

White Blood Cell (WBC) Count Differential

WBC Type Relative Value

Absolute Value uL (mm3)

Neutrophils (total) 50-70% 2,500 – 7,000

segmented (polys) 50-65% 2,500 – 6,500

bands 0-5% 0 – 500

Eosinophils 1-3% 100 - 300

Basophils 0.4-1.0% 40-100

Monocytes 4-6% 200-600

Lymphocytes 25-35% 1,700-3,500

Kee, J.L. Laborator & Diagnositc Tests with Nursing Implications. 1999.

Neutropenia Risk Factors

■ Pre-existing neutropenia

– Comorbidities, previous treatment

■ Myelosuppressive chemotherapy

■ Bone marrow involvement

■ Immune system degeneration

■ Hepatic and renal dysfunction

■ Malnutrition

■ Combined modality treatment

Assessing Neutrophils:

The Absolute Neutrophil Count (ANC)

A NC = Total WBC X % of neutrophils (segs + bands)

Example:

WBC = 2,500/mm3

Segmented neutrophils = 35%

Band neutrophils = 10%

A NC = 2,500 X (.35 + .10) =

A NC = 2,500 X .45 = 1,125/mm3

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Absolute Neutrophil

Count Calculation

WBC = 3,000/mm3

• Segmented neutrophils = 20%

• Band neutrophils = 5%

• Eosinophils = 3%

• Basophils = 1%

• Lymphocytes = 71%

What is the ANC?

ANC = 3,000/mm3 X .25 = 750

The ANC Predicts the Risk for Infection

Absolute Neutrophil Count

Grade

Risk of Infection

Within normal limits

0 No Risk

> 1,500 to <2,000 1 No significant risk

> 1,000 to < 1,500 2 Minimal risk

> 500 to <1,000 3 Moderate risk

< 500 4 Severe risk

Camp-Sorrell, D. In Itano, J. & Taoka, K. eds. Core Curriculum for Oncology Nursing, 4 th Ed. 2005: 259-274.

Potential Consequences of Neutropenia

■ Delay in administering treatment on

time or dose delay; dose reductions

■ Infection

■ Sepsis and septic shock

■ Death

Camp-Sorrell, D. In Itano, J. & Taoka, K. eds. Core Curriculum for Oncology Nursing, 4 th Ed. 2005: 259-274

Preventing Infection ■ Frequent hand washing

■ Daily bathing

■ Routine Central line care, including

chlorhexidine baths for hospitalized

patients at high risk for CLABSI

■ Frequent mouth care

■ Limit invasive procedures

– Rectal temps, catheters, etc.

■ Flu Vaccine for staff, caregivers and

patients

■ Visitor hygiene

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Nursing Management:

Continual Assessment for Infection

■ Signs of infection MAY NOT be present

■ Redness, inflammation, and drainage may be

minimal or absent

Shelton, B.K. (2009). In Gobel, B.H. et al (eds.). Advanced Oncology Nursing Certification: Review and Resource Manual, ONS, pgs. 405-442.

Nursing Assessment: Every 4 hours (inpatient) & at each clinic visit (outpatient)

■ Vital signs every 4 hours

■ Level of consciousness

■ Intake and output

■ Respiratory status & auscultate lungs

■ Presence, character and amount of sputum, cough

■ Skin integrity, especially at catheter or tube insertion sites,

incisions or perirectal area

■ Oral cavity for plaque, thrush,

ulcers, redness, dryness

■ Character, amount and frequency of stool

■ Character, amount and frequency of urine

■ Assess peri-anal area daily for

signs of infection for patients who are severely neutropenic

■ Monitor CBC and other labs for changes, if ordered

■ Assess central venous access site for signs of infection

■ Consider MD order for GCSF

Putting Evidence Into Practice (PEP) Resources

■ Green = GO!

– Recommended for Practice

– Likely to Be Effective

– Evidence supports the consideration of these interventions in practice

■ Yellow = CAUTION!

– Benefits Balanced with Harm

– Effectiveness Not Established

– Not sufficient evidence to say whether these interventions are effective or not

■ Red = STOP!

– Effectiveness Unlikely

– Not Recommended for Practice

– Evidence indicates these interventions are ineffective or harmful

https://www.ons.org/practice-resources/pep , accessed June 10, 2014

Prevention of Infection (General):

Recommended for Practice ■ Hand Hygiene with alcohol sanitizer

■ Contact precautions for resistant organisms

■ Colony-stimulating factors – Chemotherapy with > 20% risk of febrile

neutropenia or at risk patients

■ Influenza vaccine annually for all cancer patients

– 2 weeks prior to or 3 months after immunosuppressive therapy

■ Catheter care bundle

https://www.ons.org/practice-resources/pep/prevention-infection/prevention-infection-general, accessed June 10, 2014.

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Medical Management: Myeloid Growth Factors

■ Filgrastim (Neupogen) or Tbo-Filgrastim (Granix) or filgrastim-sndz (Zarxio)

– Daily dose of 5 mcg/kg until post-nadir ANC recovery to normal or near-normal levels

– Start 24-72 h after completion of chemotherapy and treat through post-nadir recovery

– Administration of growth factor on same day of therapy is not recommended

■ Pegfilgrastim (Neulasta)

– One dose of 6 mg per cycle of treatment

– Start 24-72 h after completion of chemotherapy

NCCN (2009). Myeloid Growth Factors: Practice Guidelines. Accessed at www.nccn.org, 08/24/09

Recommended for Practice (General)

■ Pneumococcal vaccine for all cancer patients

– At least 2 wks prior to chemo, if possible

■ Antibiotic prophylaxis with flouroquinolones for patients at high risk for infection

– Hematologic malignancies

– BMT recipients

– Expected neutropenia > 7 days

■ Antifungal & antiviral prophylaxis in high-risk patients

– Acute leukemia, MDS

– BMT, patients with GVHD

https://www.ons.org/practice-resources/pep/prevention-infection/prevention-infection-general, accessed June 10, 2014.

Likely to Be Effective (General)

■ Preconstruction planning

■ Chlorhexidine impregnated washcloths – chlorhexidine bath

■ Antibiotic impregnated IV catheters in adults (short-term catheters only)

■ Antibiotic abdominal lavage in colorectal surgery

https://www.ons.org/practice-resources/pep/prevention-infection/prevention-infection-general, accessed June 10, 2014.

Benefits Balanced with Harm (General)

■ Intravenous Immunoglobulin (IVIG)

https://www.ons.org/practice-resources/pep/prevention-infection/prevention-infection-general, accessed June 10, 2014.

Effectiveness Not Established (General) ■ Chlorhexidine sponge dressing

■ Protective isolation

■ Staff training

■ Cranberry juice

■ Antibiotic IV catheter lock

solutions

■ Antibiotic coated sutures

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Effectiveness Unlikely

■ Restriction of fresh fruits and vegetables

https://www.ons.org/practice-resources/pep/prevention-infection/prevention-infection-general, accessed June 10, 2014.

Not Recommended For Practice ■ Extended post-operative antibiotics

■ Live attenuated vaccines

– Flumist (intranasal attenuated influenza vaccine)

– Varicella (chicken pox) vaccine, oral polio vaccine, & MMR vaccine

■ Implantable gentamycin sponge

Detecting Signs of Infection in Patients

with Neutropenia

■ Neutropenia: the often silent disorder

■ ON LY sign of an infection may be FEVER:

– Take temperature every 4 hours (inpatient)

– Instruct patient to take temperature QD or BID (home)

– Report temperature > 1010F (38.00C) or 100.50 F (37.50 ) for > 1 hr

– Tachycardia & tachypnea alone, may be developing sepsis

– Hypotension with above indicates severe sepsis

Shelton, B.K. (2009). In Gobel, B.H. et al (eds.). Advanced Oncology Nursing Certification: Review and Resource Manual, ONS, pgs. 405-442.

Educate Patients & Caregivers to

Recognize & Minimize Infection

■ List measures to prevent infection

– Managing environment, hygiene, diet, activity

■ Identify signs & symptoms of infection

■ Emphasize when to report

– Fever or other signs/symptoms of infection

– Be specific about whom and when to call

■ Give specific oral & written instructions

Camp-Sorrell, D. In Itano, J. & Taoka, K. eds. Core Curriculum for Oncology Nursing, 4th Ed. 2005: 259-274.

Febrile Neutropenia

■ ALWAYS A MEDICAL

EMERGENCY

■ Left untreated, may be fatal

■ Sepsis is lethal in 47% of

infected patients with neutrophil count <1000

Giamarellou, H. & Antoniadou, A. (2001). Infections complications of febrile leukopenia. Infectious Disease Clinics of North America, 15 : 457-482.

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Febrile Neutropenia: Definition

■ Febrile neutropenia

– Single temperature > 38.30C orally or >38.00C over 1 hr

■ Severe Neutropenia

– < 500 neutrophils/mcL or <1,000 neutrophils/mcL and a predicted decline to <500/mcL over the next 48 hrs

NCCN (2009). Myeloid Growth Factors: Practice Guidelines. Accessed at www.nccn.org, 08/24/09

Assessing/Managing

Neutropenic Patients with Fever

■ Obtain blood cultures

■ Culture suspected sites of infection

– Urine, sputum, stool, IV catheter sites, wounds

■ Chest x-ray

■ Immediate institution of broad spectrum antibiotics

■ Admission to hospital (ANC<1000)

Thrombocytopenia

■ Decrease in circulation platelets below 100,000/mm3

– Normal platelet count 150,000 – 400,000/mm3

– Life span of platelets – 8 to 10 days

Platelet Count Grade Risk of Bleeding

Within normal limits 0 No Risk

< LLN – 75,000/mm3 1 No significant risk

<75,000 – 50,000/mm3 2 Minimal risk

< 50,000 – 25,000/mm3 3 Moderate risk

< 25,000/mm3 4 Sev ere risk

Camp-Sorrell, D. In Itano, J. & Taoka, K. eds. Core Curriculum for Oncology Nursing, 4th Ed. 2005: 259-274. National Cancer Institute Cancer Therapy Evaluation Program (NCI CTEP), 2006.

Clinical Consequences of Thrombocytopenia

■ Bleeding – Internal or External

■ Refractory to platelet transfusions

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Recommended for Practice

■ Platelet thresholds:

– 10,000: majority of patients

– 20,000

■ minor procedures

■ bladder tumors, necrotic tumors, or highly

vascular tumors likely to bleed

– 40,000 – 50,000: patients undergoing

invasive procedures

■ Platelet transfusions

– Active bleeding with thrombocytopenia

■ Mesna for prevention of hemorrhagic cystitis

http ://www2.ons.org/Research/PEP/bleeding, accessed June 10, 2014

Effectiveness Not Established

■ Platelet growth factors

– Recombinant Interleukin-11 (Neumega)

■ Interventions to prevent or

attenuate menstrual bleeding

– Oral contraceptives, progesterone, etc.

http://www2.ons.org/Research/PEP/bleeding , accessed June 10, 2014

Nursing Assessment: Every 4 hours (inpatient) & at each clinic visit (outpatient)

■ Bruises, petechiae or bleeding from orifices

■ Monitor for occult or frank blood in urine, stool, or emesis

■ Hypotension or tachycardia

■ Monitor platelet count, coagulation tests (if suspect Disseminated Intravascular Coagulation)

■ Monitor hemoglobin/hematocrit

■ Monitor pad count during menses

■ Monitor for changes in level of consciousness

■ Monitor fall risk, re-evaluate and re-score as necessary

■ Assess safety of patient environment

Reportable Concerns

■ Platelet count

– <50,000/mm3 or

– new event < than 15,000 /mm3

■ ↓ BP and ↑ pulse rate

■ Occult positive results from stools, emesis or urine

■ Spontaneous bleeding (increased risk when platelets are < 15,000/mm3)

■ Alterations in neurologic signs

■ Any new or severe pain, sudden onset of pain, or a sharp exacerbation of existing pain

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Safety Concerns

Platelets < 50,000/mm3

■ No IM injections

■ No rectal temperatures

■ No suppositories (unless cleared by MD)

■ Minimize invasive procedures

■ Avoid medications that have potential to cause bleeding (i.e. anti-inflammatories, aspirin)

■ No straight edge razors

■ Consider head CT if head strike with fall or new neuro symptoms

Patient Education

■ Report signs of bleeding

■ Preventative and management measures

Anemia

■ A term that indicates a low red cell count

and a below normal hemoglobin or hematocrit level.

Hemoglobin (g/dl)

Grade

Severity of Anemia

Within normal limits 0 Normal

10 - normal 1 Mild

8 - <10 2 Moderate

6.5 - < 8 3 Severe

< 6.5 4 Life threatening

Adapted from the Common Toxicity Criteria for adverse events. Available at: http://ctep.cancer.gov/protocolDevelopment/electronic_applications/docs/ctcaev4.pdf

Anemia Pathophysiology

■ Question: What is the lifespan of a red blood cell?

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Anemia Risk Factors

■ Chemotherapy

■ Biotherapy

■ Bone marrow involvement

■ Radiation therapy

■ Bleeding

■ Age

■ Nutritional deficit

■ Abnormal metabolism

■ Medications

Nursing Assessment: Every 8 hours (inpatient) & at each clinic visit (outpatient)

■ Fatigue

■ Hypotension

■ Tinnitus

■ Headache

■ Prolonged capillary refill (monitor hemoglobin)

■ Dyspnea

■ Palpitation

■ Weakness

■ Vertigo

■ Consider MD order for erythropoietic-stimulating agent to increase RBC (i.e., erythropoietin)

Anemia Management

■ Recognize symptoms

■ Identify and manage underlying cause

– Administer iron supplements

– Consider transfusions

– Consider recombinant erythropoietin*

– Symptom management ■ Energy conservation

■ Oxygen therapy

■ Monitor labs (CBC, iron, total iron binding capacity, transferrin saturation)

Case Study ■ S.L. presents to clinic for her 4th course of

chemotherapy for breast cancer.

■ Current lab values • WBC 2.1

• ANC: 1000

■ Patient reports increasing fatigue, no fevers, no obvious bleeding

■ What is the next step?

A. Proceed with planned chemotherapy

B. Admit SL to the hospital for hydration

C. Begin antibiotics immediately

D. Teach SL infection precautions and symptoms to report.

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FATIGUE

“Cancer-related fatigue is a distressing, persistent, subjective sense of physical, emotional, or cognitive tiredness or exhaustion related to cancer or cancer treatment that is not proportional to recent activity and interferes with usual functioning”

NCCN, 2017

Cancer-Related Fatigue

■ Sleep disorders

■ Emotional distress

– Anxiety

– Depression

■ Anemia

■ Malnutrition

■ Decreased activity

■ Pain

Based on “Pharmacologic Treatment of Cancer-Related Fatigue” by J . Carroll et. al. 2007,

Oncologist, 12(Supp. 1) p. 44. Retrieved December 11, 2007, from

http://wwwtheOncologist.com.

Cancer Related Fatigue

Non-cancer comorbidities

■ Cardiac dysfunction

■ Hepatic dysfunction

■ Hypothyroidism

■ Infection

■ Neurologic dysfunction

■ Pulmonary dysfunction

Based on “Pharmacologic Treatment of Cancer-Related Fatigue” by J . Carroll et. al. 2007, Oncologist, 12(Supp. 1),

p. 44. Retrieved December 11, 2007, from http://wwwtheOncologist.com.

Fatigue Assessment

■ Fatigue scale (age appropriate)

■ Disease status (recurrent or progression)

■ Current medications

■ Review of systems

■ Onset, pattern, and duration

■ Nutritional and metabolic evaluation

■ Activity level

■ Associated or alleviating factors

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Fatigue

Recommended for Practice

■ Exercise

– Exercise interventions in patients with cancer have been provided as

■ Home-based programs

■ Patient self-managed programs

■ Supervised and unsupervised individual or group exercise sessions

■ Varying duration and frequency and can include combinations of aerobic and resistance types of activities.

h ttps://www.ons.org/in tervention/exercise-3, accessed June 10, 2014.

Fatigue: Likely to Be Effective

■ Cognitive behavioral interventions/approach for sleep

■ Energy conservation and activity management

■ Ginseng

■ Management of concurrent symptoms

■ Massage

■ Mindfulness-based stress reduction

■ Psychoeducational interventions

■ Yoga

h ttps://www.ons.org/practice-resources/pep/fatigue, accessed June 10, 2014.

Fatigue

Benefits Balanced with Harm ■ Erythropoiesis stimulating factors (ESA’s)

■ Systemic Corticosteroids

https://www.ons.org/practice-resources/pep/fatigue, accessed September 21, 2017.

■ Acupressure/puncture/stimulation

■ Animal-assisted therapy

■ Art making/art therapy

■ Body-mind-spirit therapy

■ Bupropion

■ Co enzyme Q 10

■ Cognitive Training – group

Effectiveness Not Established (Partial List)

■ Cranial Stimulation

■ Dexamphetamine

■ Expressive writing

■ Meditation

■ Melatonin

■ Methylphenidate

■ Mistletoe extract

■ Music Therapy

■ Vitamin C

Exam Questions

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In which patient population is prophylactic antibiotic use considered? (Select all that apply)

a. A patient diagnosed with AML who has recently undergone chemotherapy

b. A pediatric patient receiving combination chemotherapy and radiation therapy for osteosarcoma

c. A patient diagnosed with aggressive breast cancer on adjuvant therapy

d. A patient at extreme risk for febrile neutropenia

e. An elderly cancer patient with shingles

The normal life span of platelets is:

a. 1 to 3 days

b. 4 to 5 days

c. 6 to 7 days

d. 8 to 10 days

How is an ANC calculated?

a. % neutrophils (segs + bands) divided by total WBC

b. Total WBC divided by % neutrophils (segs + bands)

c. % neutrophils (segs + bands) multiplied by WBC

d. Actual number of neutrophils (segs + bands) multiplied by WBC

AC calls the clinic reporting a fever of 101F for the past 24 hours. This fever would not be uncommon if the patient had received any of the following:

A. Bleomycin administration

B. Naprosyn for bone pain

C. 2 units of PRBC

D. Acetaminophen for headache

E. Interferon administration

F. Vancomycin administration

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Radiation to which of the following areas can result in myelosuppression?

a. Skull, sternum, and long bones

b. Tibia, ribs, and skull

c. Ulna, sternum, & vertebrae

d. Skull, ribs, and colon

Granulocytes collectively include

a. Basophils, eosinophils, and neutrophils

b. Basophils, lymphocytes, and neutrophils

c. Eosinophils, lymphocytes, and monocytes

d. Basophils, lymphocytes, and monocytes

Patients are at a severe risk of bleeding when

a. Neutrophils are 50%

b. Lymphocytes are 30%

c. Platelets are less than 20,000 mm^3

d. Erythrocytes are 20%

What is the most common dose-limiting toxicity of chemotherapy?

a. Constipation

b. Nausea and vomiting

c. Diarrhea

d. Myelosuppression

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The normal life span of red blood cells is

a. 1 to 3 days

b. 4 to 6 days

c. 10 to 12 days

d. 120 days

THANK YOU AND GOOD LUCK!