Assessment of myelosuppression

A full blood count (FBC) provides a good indication of myelosuppression and identifies the blood cell type(s) affected.

The following describes how nurses can assess and identify neutropenia, anaemia and thrombocytopenia.

Assessment of neutropenia

Neutropenia is defined as a decrease in circulating neutrophils and can be graded based on the count as shown in Table 1.

Table 1: Grading of neutropenia

Neutropenia itself does not cause symptoms but patients with infection may present with one or more of the following:

• Changes in body temperature (≥ 37.5 or ≤36°C)
• Chills/sweats
• New or worsening cough
• Pain or difficulty passing urine
• Diarrhoea/nausea/ vomiting
• Sore mouth, nasal congestion
• Areas of redness, swelling or soreness

It is important to note that normal signs of infection may be absent in some cases due to the reduction of normal inflammatory responses. Regular assessment of vital signs is therefore crucial in order to guarantee a rapid response should neutropenic sepsis occur. Neutropenic sepsis is a potentially life-threatening complication and is a medical emergency. The definition of neutropenic sepsis varies regionally and local policies should always be adhered to, however according to the UKONS Acute Oncology Initial Management Guidelines, a fever ≥37.5 or ≤36°C should trigger an urgent assessment and medical review. NICE guidance suggests diagnosing neutropenic sepsis in patients undergoing anticancer treatment whose neutrophil count is 0.5×109 per litre or lower and who have either: a temperature >38°C or other signs and symptoms consistent with clinically significant sepsis.

If suspected, the following further investigations should be performed and broad-spectrum antibiotics administered immediately:

• Vital signs, including temperature, blood pressure, pulse, respiratory rate and oxygen saturation
• Peripheral and central line (all lumens) blood cultures
• Urinalysis +/- mid stream urine (MSU) sample
• Bacterial and viral swabbing of possible sites of infection including central lines
• Samples of sputum, stool where indicated
• Infection markers, e.g. CRP
• Full blood count, U&Es, liver function tests, clotting, lactate, blood glucose, venous blood gas
• Chest x-ray if clinically indicated
• Use of oral assessment tool, e.g. Oral Assessment Guide

The UK Sepsis Trust provides clinical tools for the urgent assessment and immediate actions for patients presenting with suspected sepsis.

Assessment of anaemia

Anaemia is defined as a decrease in the number of red blood cells in a given volume of blood or a reduction in the concentration of haemoglobin below the normal range. The latter is generally more widely used to assess anaemia.

The severity of anaemia can be graded based on the haemoglobin value as shown in Table 2.

Table 2: Grading of anaemia

Anaemia can cause a number of symptoms therefore patients should be assessed for the following:

• Fatigue
• Shortness of breath (dyspnoea)
• Pallor
• Light-headedness
• Hypotension
• Tachycardia
• Loss of libido
• Reduced cognitive function

Further assessment, where appropriate, should be made if patients present with any of the above symptoms:

• Vital signs, including temperature, blood pressure, pulse, respiratory rate and oxygen saturation
• Full patient/family history to exclude other possible causes of anaemia
• Areas of potential bleeding
• Nutritional status to exclude iron, folate and vitamin B12 deficiency
• Cognitive assessment

Assessment of thrombocytopenia

Thrombocytopenia is defined as a platelet count in peripheral blood of less than 150 x 109/L. The severity of thrombocytopenia can be graded as shown in Table 3.

Table 3. Grading of thrombocytopenia

Patients who are thrombocytopenic may present with one or more of the following symptoms:

• Bruising
• Petechiae/purpura
• Mucosal membrane bleeding/bruising
• Blood in stool, urine or vomit
• Bleeding gums
• Bleeding from intravenous lines or urinary catheters

Further assessment includes:

• Full patient/family history for other possible causes of thrombocytopenia
• Vital signs including temperature, blood pressure, pulse, respiratory rate and oxygen saturation
• Physical examination for other areas of bruising or bleeding
• Coagulation screen where indicated e.g. prothrombin time, partial thromboplastin time
• Red blood cell count for anaemia
• Nutritional status
• Urinalysis