1. Risk for Infection

Risk Factors:

• Severely decreased neutrophil count (ANC <100 cells/mm³)
• Compromised primary immune defense
• Invasive procedures (IV lines, catheters)
• Environmental exposures

Expected Outcomes:

• Patient will remain free from signs and symptoms of infection throughout hospitalization
• Patient will demonstrate proper infection prevention techniques
• Patient will identify early signs of infection requiring immediate medical attention

Nursing Interventions:

1. Implement neutropenic precautions: Place patient in a private room with positive air pressure and HEPA filtration if available. Post appropriate isolation signage. Restrict fresh flowers, plants, and standing water from room.
2. Monitor for infection signs: Assess temperature every 4 hours. Any temperature ≥38.3°C (101°F) or ≥38°C (100.4°F) sustained for over 1 hour constitutes febrile neutropenia requiring immediate intervention.
3. Practice meticulous hand hygiene: Ensure all staff and visitors perform thorough hand hygiene before entering room. Teach patient proper handwashing technique.
4. Maintain protective barriers: Utilize masks, gloves, and gowns as indicated by isolation protocol. Require masks for all visitors and staff with any respiratory symptoms.
5. Minimize invasive procedures: Avoid unnecessary invasive procedures. When essential, use maximum sterile barrier precautions for central line insertion or maintenance.
6. Implement visitor restrictions: Screen all visitors for infectious symptoms. Restrict visitors with recent exposure to communicable diseases.
7. Practice meticulous environmental cleaning: Ensure room is cleaned daily with appropriate disinfectants. Disinfect high-touch surfaces frequently.
8. Administer prophylactic medications: Administer prescribed antimicrobial prophylaxis as ordered (antibacterial, antifungal, antiviral).
9. Monitor laboratory values: Track daily CBC with differential to monitor neutrophil recovery. Report any changes immediately.

2. Ineffective Protection

Defining Characteristics:

• Deficient immunity (ANC <100 cells/mm³)
• Altered clotting (potential thrombocytopenia)
• Impaired healing
• Weakness

Related Factors:

• Bone marrow suppression
• Myelosuppressive therapies
• Drug reactions
• Autoimmune disorders

Expected Outcomes:

• Patient will demonstrate improvement in neutrophil count with treatment
• Patient will remain free from complications related to immune compromise
• Patient will verbalize understanding of protective measures

Nursing Interventions:

1. Administer colony-stimulating factors: Administer granulocyte colony-stimulating factors (G-CSF) as prescribed to stimulate neutrophil production (filgrastim, pegfilgrastim, or lenograstim).
2. Monitor medication response: Monitor ANC levels daily to assess response to G-CSF therapy. Expected rise in neutrophil count within 24-72 hours of administration.
3. Protect from trauma: Implement bleeding precautions if concurrent thrombocytopenia exists. Avoid IM injections, rectal temperatures, suppositories, and enemas.
4. Maintain skin integrity: Inspect skin daily for any breaks, rashes, or lesions. Use gentle cleansing products and avoid adhesive products when possible.
5. Perform oral care: Implement gentle oral care regimen with soft toothbrush or foam swabs. Avoid commercial mouthwashes containing alcohol.
6. Optimize nutrition: Ensure adequate protein and calorie intake to support immune function and healing. Consult dietitian for neutropenic diet recommendations if ordered.
7. Minimize exposure to pathogens: Ensure food safety with thoroughly cooked foods. Avoid raw fruits and vegetables if severely neutropenic.
8. Identify and manage potential causative agents: If medication-induced, discontinue offending agent if possible. Document drug reactions appropriately.

3. Hyperthermia

Defining Characteristics:

• Elevated body temperature above normal range (≥38.3°C/101°F)
• Flushed skin
• Increased respiratory rate
• Tachycardia
• Chills and/or rigors

Related Factors:

• Infectious process
• Inflammatory response
• Sepsis

Expected Outcomes:

• Patient will maintain body temperature within normal range
• Patient will experience prompt resolution of febrile episodes with intervention
• Patient will demonstrate understanding of fever management protocol

Nursing Interventions:

1. Implement febrile neutropenia protocol: Initiate emergency febrile neutropenia protocol at first sign of fever (≥38.3°C/101°F). Obtain blood cultures from all lumens of central lines and peripheral site before antibiotics if possible.
2. Administer empiric antibiotics: Administer broad-spectrum antibiotics within 1 hour of fever onset as ordered. Document time from fever identification to antibiotic administration.
3. Provide antipyretics: Administer prescribed antipyretics (typically acetaminophen) for symptomatic relief. Avoid NSAIDs in thrombocytopenic patients.
4. Apply cooling measures: Implement non-pharmacological cooling measures like cool cloths and environmental temperature adjustment as needed for comfort.
5. Monitor vital signs: Check vital signs every 2-4 hours during febrile episodes, including temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation.
6. Assess for source of infection: Perform system-based assessment to identify potential infection sources (respiratory, gastrointestinal, urinary, skin, IV catheter sites, oral cavity).
7. Collect specimens: Obtain ordered specimens for culture (blood, urine, sputum, stool, wound) as indicated.
8. Maintain hydration: Monitor fluid balance closely. Provide adequate hydration to compensate for insensible losses during febrile episodes.
9. Document response: Record temperature pattern, response to interventions, and associated symptoms.

4. Deficient Knowledge

Defining Characteristics:

• Verbalized misunderstanding of agranulocytosis management
• Inaccurate follow-through of instructions
• Inappropriate behaviors related to infection prevention
• Questions indicating knowledge gaps

Related Factors:

• New diagnosis
• Complex self-care requirements
• Unfamiliar medical terminology
• Anxiety interfering with learning

Expected Outcomes:

• Patient will verbalize understanding of agranulocytosis and its implications
• Patient will demonstrate proper infection prevention techniques
• Patient will identify situations requiring immediate medical attention
• Patient will verbalize medication purposes, schedules, and side effects

Nursing Interventions:

1. Assess baseline knowledge: Determine patient’s current understanding of agranulocytosis, including causes, treatment, and prevention measures.
2. Provide condition explanation: Explain agranulocytosis in simple terms, using visual aids as appropriate. Discuss how neutrophils protect against infection and why their deficiency creates risk.
3. Teach infection warning signs: Educate patient about fever (≥38°C/100.4°F), chills, new onset cough, sore throat, skin lesions, diarrhea, dysuria, and mouth sores as symptoms requiring immediate reporting.
4. Demonstrate infection prevention techniques: Teach proper handwashing technique, personal hygiene practices, food safety, and environmental considerations.
5. Review medication regimen: Provide detailed education about prescribed medications, including G-CSF administration techniques if self-administered.
6. Validate understanding: Use teach-back method to confirm comprehension. Ask patient to explain key concepts in their own words.
7. Provide written materials: Supply detailed written instructions about home care and when to seek medical attention. Include contact information for healthcare team.
8. Address barriers to learning: Identify and address factors that may impede learning such as anxiety, language barriers, or cognitive issues.
9. Include support persons: Incorporate family members or caregivers in education sessions with patient’s permission.

5. Risk for Bleeding

Risk Factors:

• Potential concurrent thrombocytopenia
• Coagulation abnormalities
• Medication side effects
• Compromised mucous membranes

Expected Outcomes:

• Patient will not experience abnormal bleeding
• Patient will demonstrate understanding of bleeding precautions
• Patient will identify and report early signs of bleeding promptly

Nursing Interventions:

1. Monitor laboratory values: Track platelet counts and coagulation studies (PT/INR, PTT). Report critical values immediately.
2. Assess for bleeding: Perform systematic assessment for bleeding (skin, oral mucosa, urine, stool, emesis, menstrual flow). Use guaiac testing as indicated.
3. Implement bleeding precautions: Avoid invasive procedures when possible. Use smallest gauge needles for necessary procedures. Apply pressure to puncture sites for at least 5 minutes.
4. Modify activities: Avoid activities with high risk for trauma. Assist with ambulation if unsteady. Use electric razor instead of blade.
5. Optimize oral care: Provide gentle oral hygiene with soft toothbrush or foam swabs. Avoid flossing if platelet count <50,000/mm³.
6. Manage medications: Review medication list for agents that affect coagulation (anticoagulants, NSAIDs, some antibiotics). Recommend alternatives when appropriate.
7. Administer blood products: Administer platelets as prescribed, typically for counts <10,000/mm³ or <20,000/mm³ with bleeding.
8. Teach bleeding precautions: Educate patient about avoiding constipation, straining, forceful nose blowing, and contact sports.
9. Document bleeding episodes: Record any bleeding events including location, duration, quantity, and interventions required.

6. Impaired Oral Mucous Membrane

Defining Characteristics:

• Oral pain or discomfort
• Ulcerations or lesions
• Bleeding gums
• Coated tongue
• Difficulty swallowing or eating

Related Factors:

• Immunosuppression
• Opportunistic infections
• Decreased platelets
• Medication side effects
• Inadequate oral hygiene

Expected Outcomes:

• Patient will maintain intact oral mucosa
• Patient will report decreased oral discomfort
• Patient will demonstrate proper oral care techniques
• Patient will maintain adequate nutritional intake

Nursing Interventions:

1. Assess oral cavity: Perform comprehensive oral assessment daily using a standardized tool (e.g., WHO Oral Mucositis Scale). Document findings.
2. Implement systematic oral care protocol: Establish gentle oral care regimen every 4 hours and after meals. Use soft toothbrush or foam swabs with non-irritating dentifrice.
3. Provide soothing rinses: Implement normal saline or sodium bicarbonate rinses 4-6 times daily. Avoid commercial mouthwashes containing alcohol.
4. Manage pain and discomfort: Administer prescribed topical anesthetics (lidocaine solutions) before meals as needed. Consider systemic pain management for severe mucositis.
5. Prevent infections: Administer prescribed antifungal prophylaxis. Monitor for oral candidiasis (white patches, redness, discomfort).
6. Promote hydration: Encourage frequent small sips of water. Provide ice chips if not contraindicated.
7. Modify diet: Offer soft, bland, non-irritating foods. Avoid spicy, acidic, rough, or extremely hot/cold foods.
8. Monitor nutritional status: Track daily caloric intake. Request nutritional consultation if intake is inadequate.
9. Provide lip care: Apply water-based lubricants to lips every 2 hours.

7. Fatigue

Defining Characteristics:

• Verbalized overwhelming lack of energy
• Inability to maintain usual routines
• Decreased performance
• Increased rest requirements
• Lethargy or listlessness

Related Factors:

• Anemia (if present)
• Disease process
• Increased metabolic demands
• Medication side effects
• Inadequate nutrition
• Sleep disturbances

Expected Outcomes:

• Patient will report improved energy levels
• Patient will balance activity and rest appropriately
• Patient will identify energy conservation strategies
• Patient will maintain adequate nutritional intake to support energy needs

Nursing Interventions:

1. Assess fatigue severity: Use numeric rating scale (0-10) to quantify fatigue levels. Document pattern, aggravating factors, and alleviating factors.
2. Monitor contributing factors: Check hemoglobin/hematocrit values. Assess sleep patterns, nutritional intake, and medication side effects.
3. Plan activities around energy patterns: Schedule important activities or procedures during peak energy times. Allow for rest periods between activities.
4. Implement energy conservation techniques: Teach patient to prioritize activities, use assistive devices, sit instead of stand when possible, and delegate non-essential tasks.
5. Promote optimal nutrition: Offer small, frequent, nutrient-dense meals. Ensure adequate protein and calorie intake.
6. Encourage progressive activity: Implement graduated activity plan, starting with passive range of motion and progressing as tolerated. Consult physical therapy as appropriate.
7. Improve sleep quality: Establish consistent sleep routine. Minimize nighttime disruptions. Create restful environment.
8. Administer prescribed treatments: Administer blood transfusions or erythropoiesis-stimulating agents as ordered for anemia-related fatigue.
9. Address psychological factors: Evaluate for depression or anxiety that may contribute to fatigue. Provide appropriate support or referrals.

8. Anxiety

Defining Characteristics:

• Expressed concerns about health status
• Restlessness
• Insomnia
• Increased tension
• Focus on self
• Worried about change in life events

Related Factors:

• Serious health threat
• Uncertainty about prognosis
• Infection risk awareness
• Role changes
• Knowledge deficit

Expected Outcomes:

• Patient will verbalize decreased anxiety levels
• Patient will demonstrate effective coping strategies
• Patient will report improved sleep patterns
• Patient will participate in care decisions appropriately

Nursing Interventions:

1. Assess anxiety level: Use standardized anxiety assessment tool to establish baseline and track progress. Identify specific triggers and concerns.
2. Establish therapeutic relationship: Use active listening and presence. Acknowledge fears and concerns. Provide empathetic, non-rushed interactions.
3. Provide accurate information: Explain all procedures, treatments, and expected sensations. Correct misconceptions. Use clear, non-medical language.
4. Teach anxiety reduction techniques: Instruct in deep breathing, progressive muscle relaxation, guided imagery, and mindfulness practices.
5. Create calm environment: Reduce unnecessary noise and disruptions. Adjust lighting to preference. Limit number of visitors if overwhelming.
6. Promote sense of control: Involve patient in care decisions when possible. Provide choices within safe parameters.
7. Encourage expression of feelings: Create opportunities for patient to express fears, frustrations, and concerns. Validate emotional responses as normal.
8. Facilitate support systems: Encourage family involvement. Connect with chaplain services or social work as appropriate. Consider peer support resources.
9. Administer anxiolytic medications: Administer prescribed anti-anxiety medications as needed. Monitor effectiveness and side effects.

9. Risk for Decreased Cardiac Output

Risk Factors:

• Potential concurrent anemia
• Sepsis
• Fluid imbalances
• Medication side effects
• Pre-existing cardiac conditions

Expected Outcomes:

• Patient will maintain stable vital signs within patient’s normal range
• Patient will display adequate tissue perfusion
• Patient will demonstrate activity tolerance appropriate for condition

Nursing Interventions:

1. Monitor cardiovascular status: Assess vital signs every 4 hours or more frequently if unstable. Note heart rate, rhythm, blood pressure, respiratory rate, and oxygen saturation.
2. Monitor for sepsis indicators: Assess for early signs of sepsis (tachycardia, tachypnea, altered mental status). Implement sepsis protocol if indicated.
3. Evaluate tissue perfusion: Check capillary refill, skin color and temperature, peripheral pulses, level of consciousness, and urine output.
4. Monitor fluid balance: Maintain accurate intake and output records. Assess for signs of dehydration or fluid overload.
5. Position for optimal cardiac function: Elevate head of bed 30-45 degrees unless contraindicated. Avoid activities that increase cardiac workload during periods of instability.
6. Administer blood products: Administer prescribed red blood cell transfusions for significant anemia. Monitor for transfusion reactions.
7. Administer medications: Give prescribed cardiac medications, vasopressors, or fluid resuscitation as ordered. Monitor response and side effects.
8. Monitor laboratory values: Track hemoglobin/hematocrit, electrolytes (particularly potassium, magnesium, calcium), cardiac enzymes if indicated, and ABGs or oxygen saturation.
9. Obtain ECG: Record baseline ECG and repeat with any significant changes in cardiac status.

10. Imbalanced Nutrition: Less than Body Requirements

Defining Characteristics:

• Inadequate food intake
• Weight loss
• Oral mucosa lesions
• Lack of interest in food
• Altered taste sensation
• Abdominal pain or discomfort

Related Factors:

• Oral mucositis
• Nausea and vomiting
• Increased metabolic demands
• Medication side effects
• Fatigue
• Dietary restrictions (neutropenic diet)

Expected Outcomes:

• Patient will maintain stable weight within 5% of baseline
• Patient will consume adequate calories and protein for metabolic needs
• Patient will verbalize strategies to improve nutritional intake

Nursing Interventions:

1. Assess nutritional status: Monitor daily weight, caloric intake, and protein consumption. Document meal percentages consumed.
2. Consult dietitian: Request nutritional assessment and recommendations tailored to patient’s condition and preferences.
3. Implement neutropenic diet if ordered: Follow facility protocol for food safety in neutropenic patients. Generally includes well-cooked foods and avoidance of raw fruits/vegetables.
4. Manage symptoms affecting intake: Administer prescribed antiemetics 30 minutes before meals for nausea. Provide mouth care before meals for oral discomfort.
5. Optimize meal environment: Create pleasant eating environment free from unpleasant odors. Schedule care activities to avoid interrupting meals.
6. Offer frequent small meals: Provide 6-8 small, nutrient-dense meals rather than 3 larger ones. Include high-protein, high-calorie options.
7. Provide oral supplements: Offer prescribed nutritional supplements between meals. Find flavors preferred by patient.
8. Monitor laboratory values: Track albumin, prealbumin, total protein, electrolytes, and other nutritional indicators.
9. Initiate alternative feeding methods: Prepare patient for enteral or parenteral nutrition if oral intake remains inadequate despite interventions.

11. Risk for Impaired Skin Integrity

Risk Factors:

• Immunocompromised status
• Poor tissue perfusion
• Potential nutritional deficits
• Decreased mobility during illness
• Moisture from diaphoresis during febrile episodes

Expected Outcomes:

• Patient will maintain intact skin throughout hospitalization
• Patient will demonstrate proper skin care techniques
• Patient will identify early signs of skin breakdown

Nursing Interventions:

1. Perform comprehensive skin assessment: Inspect all skin surfaces daily, with particular attention to pressure points, skin folds, and perineal area. Document findings.
2. Implement regular repositioning: Assist with position changes every 2 hours if mobility is limited. Use proper positioning techniques and devices.
3. Provide appropriate support surfaces: Ensure mattress provides adequate pressure redistribution. Add specialty mattress if risk assessment indicates.
4. Maintain skin hygiene: Use mild, pH-balanced cleansers. Avoid hot water. Pat rather than rub skin dry.
5. Manage moisture: Apply moisture barrier products to areas at risk for moisture-associated skin damage. Change linens promptly when damp.
6. Minimize friction and shear: Use lift sheets when repositioning. Elevate head of bed no more than 30 degrees unless medically necessary.
7. Apply preventive skin products: Use approved moisturizers on dry skin. Apply protective barriers on high-risk areas.
8. Promote nutrition and hydration: Ensure adequate protein, vitamin C, zinc, and fluid intake to support skin health.
9. Monitor invasive device sites: Check all catheter insertion sites, drain sites, and tape/dressing edges for skin irritation or breakdown.

12. Readiness for Enhanced Self-Care

Defining Characteristics:

• Expressed desire to enhance knowledge of self-care strategies
• Expressed desire to enhance independence with health management
• Demonstrated adequate problem-solving abilities
• Expressed desire to enhance responsibility for health maintenance

Expected Outcomes:

• Patient will demonstrate competence in required self-care activities
• Patient will verbalize understanding of follow-up care requirements
• Patient will identify appropriate community resources
• Patient will successfully transition to home management

Nursing Interventions:

1. Assess readiness for enhanced self-care: Evaluate patient’s current knowledge, skills, motivation, and resources for self-management.
2. Provide comprehensive education: Teach about medication administration, infection prevention, symptom monitoring, and when to seek medical attention.
3. Incorporate teach-back method: Ask patient to demonstrate understanding by explaining concepts in their own words. Validate competency with return demonstrations of skills.
4. Develop individualized home care plan: Create written plan addressing specific needs and challenges in home environment.
5. Connect with community resources: Provide information about support groups, home health services, transportation assistance, and other relevant community resources.
6. Ensure medication access: Confirm patient has access to prescribed medications. Address financial concerns and insurance issues.
7. Coordinate follow-up appointments: Schedule necessary follow-up appointments before discharge. Ensure patient understands importance of keeping these appointments.
8. Provide emergency contact information: Ensure patient has clear instructions on who to contact in emergency situations and what constitutes an emergency.
9. Document readiness: Record patient’s demonstrated understanding and skill acquisition. Note areas requiring reinforcement.