Chemotherapy at Home: Symptom Management, Bleeding and Infection Precautions, and Neutropenic Fever
Teach scheduled antiemetic use, oral care with a soft toothbrush and salt and baking soda rinses, and bleeding and infection precautions during the nadir. A temperature of 100.4 F (38 C) or higher requires an immediate call to the oncology team, because neutropenic fever is an oncologic emergency. Call 911 for dyspnea, chest pain, bleeding that does not stop, or confusion.
Who needs this teaching
Clients receiving chemotherapy and the caregiver. Chemotherapy destroys rapidly dividing cells, including cells of the bone marrow, oral mucosa, gastrointestinal tract, and hair follicles. White blood cell and platelet counts reach their lowest point (nadir) usually 7 to 14 days after treatment. Infection and bleeding risks are highest during the nadir.
The priority teaching points
- Nausea and vomiting. Take the prescribed antiemetics on schedule, before nausea starts, including on the days after treatment. Delayed nausea continues for several days. Eat small, frequent, bland meals. Avoid fatty, fried, spicy, and strong-smelling foods. Sip fluids between meals.
- Mucositis. Inspect the mouth daily. Brush with a soft toothbrush after meals and at bedtime. Rinse with a salt and baking soda solution several times a day. Avoid alcohol-based mouthwash, tobacco, alcohol, and acidic, spicy, or hot foods. Report ulcers, white patches, or pain that prevents eating.
- Fatigue. Fatigue is the most common symptom during chemotherapy. Balance rest periods with light activity such as short walks; regular activity reduces cancer-related fatigue. Plan important tasks for times of highest energy.
- Alopecia. Hair loss usually begins 2 to 3 weeks after the first treatment and is temporary. Use a mild shampoo and a soft brush. Protect the scalp with a hat and sunscreen.
- Diarrhea and constipation. For diarrhea, drink extra fluids, eat low-fiber foods, and take the prescribed antidiarrheal. Report more than 4 to 6 loose stools a day. For constipation, increase fluids, fiber, and activity, and follow the prescribed bowel regimen.
- Thrombocytopenia precautions. Normal platelet count is 150,000 to 400,000/mm3. When platelets are low, use a soft toothbrush and an electric razor, blow the nose gently, and avoid contact sports, rectal temperatures, enemas, and suppositories. Avoid aspirin and NSAIDs unless the oncology team prescribes them.
- Neutropenia precautions. An absolute neutrophil count (ANC) below 500/mm3 indicates severe neutropenia. Perform frequent hand hygiene. Avoid crowds and people with infections. Cook meat and eggs thoroughly and wash raw fruits and vegetables. Do not clean litter boxes, bird cages, or fish tanks. Ask before any vaccine, and avoid live vaccines.
- Neutropenic fever. Check the temperature when feeling unwell or chilled. A temperature of 100.4 F (38 C) or higher requires an immediate call to the oncology team, at any hour. Neutropenia blunts the inflammatory response, so fever is often the only sign of infection. Do not take a fever reducer before calling.
Red flags the client reports
| Call the provider the same day | Call 911 or the local emergency number |
|---|---|
| Temperature of 100.4 F (38 C) or higher, or shaking chills: call the oncology team at once | Dyspnea or chest pain |
| Vomiting that prevents fluid intake for 24 hours | Bleeding that does not stop with firm pressure |
| More than 4 to 6 loose stools a day | New confusion or difficulty waking |
| Mouth sores that prevent eating or drinking | Vomiting blood, or black, tarry stool |
| New petechiae, bruising, or bleeding gums | Syncope |
Teach-back questions
- "What temperature means you call the oncology team right away?"
- "When will you take your nausea medicine?"
- "Show me how you will clean your mouth."
- "Which pain relievers will you avoid while your platelets are low?"
- "Which symptoms mean you call 911?"
Teaching tips
- Write the oncology team's 24-hour phone number and the expected nadir dates on the handout.
- Confirm the client owns a thermometer and observe a correct reading.
- Include the caregiver in infection and bleeding precautions.
Read more on NCLEXPace
Sources
- Harding MM, Kwong J, Hagler D, Reinisch C. Lewis's Medical-Surgical Nursing: Assessment and Management of Clinical Problems. 12th ed. Elsevier; 2023; Chapters: Cancer; Hematologic Problems.
- Taplitz RA, et al. Outpatient Management of Fever and Neutropenia in Adults Treated for Malignancy: American Society of Clinical Oncology and Infectious Diseases Society of America Clinical Practice Guideline Update. J Clin Oncol. 2018;36(14):1443-1453.
- Hesketh PJ, et al. Antiemetics: ASCO Guideline Update. J Clin Oncol. 2020;38(24):2782-2797.
- Elad S, et al. MASCC/ISOO Clinical Practice Guidelines for the Management of Mucositis Secondary to Cancer Therapy. Cancer. 2020;126(19):4423-4431.
Why this matters for the NCLEX
Teaching is effective when the client states, "I will call my oncology team right away if my temperature is 100.4 or higher," and "I will take my nausea medicine on schedule, even before I feel sick." Statements requiring further teaching include, "I will take my temperature rectally," "I will use my alcohol mouthwash on the sores," and "I will take ibuprofen for my headache while my platelets are low."
Frequently asked questions
Why does a temperature of 100.4 F (38 C) require an immediate call when the client feels otherwise well?
Neutropenia blunts the inflammatory response, so fever is often the only sign of infection. Neutropenic fever is an oncologic emergency, and early antibiotics prevent progression to sepsis.
Does the client wait for nausea before taking the antiemetic?
No. Scheduled antiemetics prevent nausea. Prevention is more effective than treatment of established vomiting.
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