NURSING CARE FOR PATIENTS WITH BLOOD CONDITIONS

Many patients with blood conditions will have abnormalities of their blood count.  This may be the result of:

q       The underlying disease affecting their bone marrow and altering the production of normal blood cells.

q       The side effects of treatment (most commonly chemotherapy) for their blood disorder. 

The most common abnormalities are 

Anaemia

 Low red blood cells.  This causes pallor, tiredness, shortness of breath on exertion, worsening of angina.

Thrombocytopenia

Low platelet count.  This results in a tendency to bruise easily, or without trauma.  Nose or mouth bleeds, small dot like haemorrhages under the skin (petechiae), bleeding from venepuncture sites, non visible bleeding into the brain retina or organs.

Neutropenia

Low neutrophil count though the total white count may be high.  This results in a proneness to infections, where the usual signs may not be present due to lack of white cells.  Most common are respiratory infections, perianal abscess, skin infections (cannula sites are common) and septicaemia.  There is an increased incidence of herpes and fungal infections in these patients.  This proneness to infection may be compounded by the administration of steroids.

Patients with blood conditions require precise nursing care that incorporates awareness of and observation for the specific problems that may arise, so that prompt and appropriate actions is taken.

Thrombocytopenia

Patients who have a platelet count of 20 or less can have spontaneous bruising or bleeding.  This bleeding may be visible ie nose bleeds or concealed like a brain haemorrhage. 

       Nursing Care 

q         No aspirin or non steroidal anti-inflammatory drugs to be given.

q         Daily urine test for haematuria.

q         Assess for oral, scleral, rectal, nasal or vaginal bleeding.

q         Patient/staff to observe bowels for any dark bowel motions.

q         No PR examinations, suppositories or enemas without specific medical orders.

q         BD examination of oral mucosa for haematoma.

q         A soft toothbrush should be used for oral hygiene.

q         Avoid frequent monitoring of BP using automatic machines as the high pressure can cause bleeding.  Use a manual machine.

q         All venepuncture sites to have a pressure bandage applies for 15 minutes.

q         No IM injections.  Subcutaneous injections are permissible but the site must have pressure applied for a few minutes.

q         Urinary catheters are to be avoided as they can cause haematuria.

q         An electric razor should be used for shaving, no wet shaving.

q         Any blurred or loss of vision to be investigated as it is possible to have retinal haemorrhages.

q         Anti emetic therapy is given to prevent vomiting which can precipitate bleeding problems.

Neutropenic Patients/Reverse Barrier Nursing Guidelines 

Patients who have a neutrophil count of less than 0.5% x 10⁹/l require protective isolation/reverse barrier nursing.

q         Single room isolation.

q         Barrier Nursing card displayed.

q         All items entering the room must be cleaned, disinfected or sterile as appropriate.

q         Any person, staff or visitor on entry to the room are to thoroughly wash their hands and a disposable plastic apron worn.

q         Medical staff should remove white coats prior to entering the room.

q         Gloves need only be worn as per universal precautions for blood or body fluids.

q         No special precautions are required for used linen, waste or other equipment.

q         Any staff member or visitor with any cold, sore throat or infection should be excluded from visiting or entering the room.

q         Staff caring for any other patient with an active infection should avoid entering the room.

q         Limit exposure to fresh flowers or plants.

Specific Nursing Care for Neutropenic Patients

q         4 hourly temperature observations.  A temperature of 38.0°C sustained for an hour, or a single reading of >38.5°C is significant and must be reported to the medical SHO on-call.  IV antibiotic therapy must be commenced within 2 hours.  Paracetamol is not to be given to suppress fevers.

q         Neutropenic patients can be septic with little elevation in the temperature.

q         Daily observation for any reddened swollen or painful skin lesions, neutropenic patients may not form pus with an infection.  Any lesion should have a microbiological swab performed.

q         Qid mouth care as per oral care protocol and daily oral assessment and observation for oral thrush.

q         Twice daily deep breathing and coughing.

q         Bowels to be monitored and kept regular, constipation and straining can lead to anal fissures and tears that become infected. 

q         Rectal examinations, suppositories and enemas and urinary catheters are only to be a the instigation of a senior clinician.

q         Peripheral IV cannulas must be replaced every 48 hours or sooner if painful or reddened.

q         Any symptom such as cough, urinary urgency, sore throat, diarrhoea must be investigated.  Patients who are generally unwell, confused or agitated may be septic and go into septic shock.  The medical SHO must be asked to assess the patient.

q         Observation for any signs of Herpes infections.  Patients with a previous history of cold sores must be asked to report any pain, tingling or burning sensations, redness or blisters.  Prompt commencement of treatment is necessary.

q         Weekly microbiological screening of MSU, sputum, faeces, central catheter exit site and throat swab.