Neutropenic Sepsis: Building Marianne’s Nursing Care Plan
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Marianne’s story did not end when her deterioration was recognised.
In the original scenario, Marianne Lowe was admitted after four days of worsening nausea, diarrhoea, painful oral ulcers, poor intake and extreme fatigue following cycle 2 of chemotherapy for breast cancer. She was neutropenic and clinically unwell, with tachycardia, tachypnoea, relatively low blood pressure, prolonged capillary refill, dehydration, hypokalaemia and thrombocytopenia. The immediate priority was urgent escalation and treatment for suspected neutropenic sepsis.
This continuation moves from recognising the emergency to planning, delivering and evaluating Marianne’s nursing care. It is a worked educational example, not a care plan to copy into clinical documentation.
Read Marianne’s original chemotherapy deterioration scenario first
Marianne after urgent review and initial treatment
Marianne was reviewed immediately by the registered nurse, medical team and Acute Oncology Service. The local neutropenic sepsis pathway was started. Blood cultures and other investigations were obtained without delaying empiric intravenous antibiotics. She received carefully assessed intravenous fluids, prescribed antiemetic treatment, analgesia, mouth care and potassium replacement. Stool testing and infection-prevention precautions were initiated because diarrhoea can be caused by treatment toxicity, infection or another acute gastrointestinal problem.
Four hours later, Marianne remains on the oncology ward. Her current observations are:
- Respiratory rate: 19 breaths/min
- SpO₂: 97% on room air
- Heart rate: 94 bpm
- Blood pressure: 108/66 mmHg
- Temperature: 37.6°C
- GCS: 15
Her neutrophil count remains 0.4 × 10⁹/L, platelets are 95 × 10⁹/L and haemoglobin is 9.2 g/dL. Potassium is being rechecked after prescribed replacement. Marianne has passed urine but remains in a positive fluid deficit because of diarrhoea and limited intake. Her mouth is painful and she can manage only small sips. She has had another loose stool, which has been documented and sampled as requested.
Marianne says the mouth pain is currently worse than the nausea. She is frightened that this complication means her cancer treatment has failed and is worried about missing work. She wants her husband involved but asks staff to speak to her first.
Before you see the worked plan
Which needs would you prioritise now?
- Why does Marianne remain at risk even though her observations are improving?
- Which findings need continued emergency monitoring?
- How are diarrhoea, poor intake and low potassium connected?
- What risks arise from mucositis and thrombocytopenia?
- What matters to Marianne beyond the blood results?
Ongoing treatment and surveillance for neutropenic sepsis remain the first priority. Fluid and electrolyte loss, diarrhoea, mucositis, nutrition, bleeding risk, fatigue and psychological support must then be integrated into the plan.
Worked care plan
Priority 1: Suspected neutropenic sepsis and ongoing infection risk
Assessed need or nursing problem
Marianne has suspected neutropenic sepsis following recent systemic anti-cancer therapy. Her observations have improved after initial treatment, but severe neutropenia limits her ability to respond to infection and she remains at risk of rapid deterioration.
Evidence
- Neutrophil count 0.4 × 10⁹/L
- Recent chemotherapy and four days of worsening symptoms
- Initial heart rate 104 bpm, blood pressure 98/60 mmHg and respiratory rate 22 breaths/min
- Initial prolonged capillary refill and cool peripheries
- Diarrhoea, mucositis and clinical dehydration
- Temperature 37.9°C at presentation, with other signs of clinically significant illness
Agreed outcome
Marianne will receive time-critical treatment and close reassessment. Her observations and clinical condition will remain stable or improve, prescribed antimicrobials will be administered safely and on time, and any deterioration or new infection focus will be escalated immediately.
Nursing actions and rationale
- Continue A–E reassessment, NEWS2 observations and escalation at the frequency set by the responsible team and local neutropenic sepsis pathway. Do not use a normal or near-normal temperature as reassurance if Marianne looks or feels unwell.
- Administer prescribed empiric antibiotics immediately and subsequent doses at the correct time after completing identity, allergy, medicine, dose, route and clinical checks. NICE treats suspected neutropenic sepsis as an acute medical emergency.
- Monitor blood pressure, heart rate, respiratory rate, oxygen saturation, temperature, perfusion, urine output and mental state as a connected picture.
- Support prescribed cultures, blood tests, lactate monitoring and assessment of possible infection sources, including mouth, skin, vascular-access devices, respiratory symptoms, urine and gastrointestinal symptoms.
- Use standard infection-prevention precautions and any additional precautions indicated by symptoms, investigation results and local policy. Protective care should not become unnecessary social isolation.
- Inspect and document the vascular-access site if present, using local device-care policy. Escalate redness, pain, discharge, swelling, line damage or suspected infection.
- Ensure Marianne knows how to call for help and encourage her to report chills, feeling suddenly worse, breathlessness, pain, dizziness, bleeding or any new symptom immediately.
Monitoring and evaluation
Trend Marianne’s observations, perfusion, blood results, cultures, symptoms and response to treatment. Improvement in heart rate and blood pressure is encouraging but does not end the risk while she remains profoundly neutropenic. Any recurrent hypotension, rising respiratory rate, altered cognition, reduced urine output, rigors, increasing lactate or new clinical concern requires urgent escalation.
Priority 2: Diarrhoea, dehydration and electrolyte disturbance
Assessed need or nursing problem
Marianne has ongoing gastrointestinal fluid loss and poor oral intake with hypokalaemia. Causes may include systemic anti-cancer therapy toxicity, infection, medicines or another gastrointestinal condition, so the cause must not be assumed.
Evidence
- Four days of diarrhoea, nausea and poor intake
- Dry mucous membranes and cracked lips
- Initial blood pressure 98/60 mmHg and prolonged capillary refill
- Potassium 3.3 mmol/L and sodium 132 mmol/L
- Ongoing loose stool after admission
Agreed outcome
Marianne’s circulation, hydration and electrolytes will stabilise. Stool frequency and characteristics, intake, output and symptoms will be documented accurately, prescribed replacement will be given safely, and features suggesting infection or severe treatment toxicity will be escalated.
Nursing actions and rationale
- Record stool frequency, approximate volume where possible, consistency, colour, blood or mucus, urgency, nocturnal symptoms, abdominal pain and associated vomiting. “Diarrhoea present” is not enough information to evaluate change.
- Follow local infection-prevention policy and obtain stool specimens when requested. Infective diarrhoea must be considered, particularly in a neutropenic patient.
- Maintain accurate oral and intravenous intake, urine output and gastrointestinal-loss records. Monitor weight when clinically appropriate and safe.
- Support prescribed intravenous or oral fluid and electrolyte replacement, with repeated reassessment for response and overload.
- Administer potassium only as prescribed and according to local medicines policy. Intravenous potassium is a high-risk medicine and must never be given by intravenous push. Students should participate only within competence and direct supervision requirements.
- Monitor repeat electrolytes, renal function, cardiac symptoms and electrocardiogram findings when requested. Report palpitations, muscle weakness, worsening fatigue or other concerns.
- Do not give anti-diarrhoeal medicines unless they have been clinically assessed and prescribed. They may be inappropriate where infection, ileus, severe colitis or particular treatment toxicities are suspected.
- Provide gentle perineal skin care and a prescribed or locally approved barrier product where appropriate, preserving privacy and dignity.
Monitoring and evaluation
Review stool frequency, intake, urine output, fluid balance, observations, electrolytes, renal function, abdominal symptoms and skin condition. The plan is progressing if losses reduce and hydration and potassium improve without overload. Increasing diarrhoea, severe abdominal pain, blood in stool, ileus, hypotension, fever or worsening clinical condition requires urgent review.
Priority 3: Oral mucositis, pain and reduced intake
Assessed need or nursing problem
Marianne has painful chemotherapy-associated oral mucositis that limits drinking and eating and may provide a route for infection. Thrombocytopenia also increases the importance of gentle oral care.
Evidence
- Several painful oral ulcers, cracked lips and dry mucosa
- Marianne identifies mouth pain as her most troubling symptom
- Minimal oral intake
- Neutrophils 0.4 × 10⁹/L and platelets 95 × 10⁹/L
Agreed outcome
Marianne’s mouth pain will be assessed and reduced enough to support communication, hydration and nutrition. Oral tissues will be monitored for deterioration, bleeding or secondary infection, and care will follow her oncology team’s mouth-care plan.
Nursing actions and rationale
- Assess and document the mouth systematically, including pain, erythema, ulceration, bleeding, coating, dryness, swallowing difficulty and signs of secondary infection.
- Ask Marianne what products and techniques are comfortable. Provide gentle mouth care at the locally recommended frequency, using prescribed or approved products and avoiding solutions that irritate her mucosa.
- Support regular lip care and offer a soft toothbrush if clinically appropriate and tolerated. Avoid traumatic oral care and seek advice if bleeding risk increases.
- Administer prescribed analgesia and mouth treatments, then reassess pain and ability to drink or eat.
- Offer small sips and soft, moist, non-irritating foods when swallowing is safe. Avoid assuming that one standard diet will suit her.
- Assess for painful swallowing, coughing, choking or inability to manage secretions and escalate for medical, dietetic or speech and language therapy review as appropriate.
- Report worsening ulceration, uncontrolled pain, oral bleeding, suspected fungal or viral infection, inability to drink or new airway concerns.
Monitoring and evaluation
Use Marianne’s pain rating and functional ability to drink, eat, speak and sleep to evaluate care. A mouth that looks similar may still be improving if pain and intake are better. Worsening mucositis, infection, bleeding or inability to maintain intake requires review.
Priority 4: Bone marrow suppression, bleeding risk and fatigue
Assessed need or nursing problem
Marianne has chemotherapy-related bone marrow suppression affecting neutrophils, platelets and haemoglobin. This contributes to infection risk, bleeding risk and fatigue.
Evidence
- Neutrophils 0.4 × 10⁹/L
- Platelets 95 × 10⁹/L
- Haemoglobin 9.2 g/dL
- Extreme fatigue and weakness
- Painful oral ulceration with potential for mucosal bleeding
Agreed outcome
Marianne will avoid preventable bleeding and injury, symptoms related to anaemia and thrombocytopenia will be recognised, and changes in blood counts or clinical condition will be escalated to the oncology team.
Nursing actions and rationale
- Monitor for bruising, petechiae, gum or nose bleeding, haematuria, melaena, heavy vaginal bleeding where relevant, prolonged bleeding from puncture sites and new severe headache or neurological symptoms.
- Minimise avoidable trauma. Use gentle oral and skin care and apply appropriate pressure after venepuncture. Decisions about invasive procedures, intramuscular injections and devices require clinical review and local policy.
- Check prescribed anticoagulants, antiplatelets and other medicines against current platelet count and bleeding risk with the registered nurse and prescriber. Do not independently omit medicines.
- Assess fatigue, dizziness, breathlessness, chest discomfort, activity tolerance and the effect on personal care. Haemoglobin should be interpreted with symptoms and the wider clinical picture.
- Support rest while preventing unnecessary bed rest and deconditioning. Mobilise safely according to observations, symptoms and falls risk.
- Support repeat full blood count and other monitoring requested by the oncology team. Blood-product decisions are made by the appropriate clinical team using the individual patient’s condition and local policy.
Monitoring and evaluation
Record bleeding, bruising, fatigue, activity tolerance and blood-count trends. Escalate active bleeding, neurological symptoms, haemodynamic change, worsening breathlessness or other significant deterioration immediately.
Priority 5: Psychological wellbeing, information and recovery planning
Assessed need or nursing problem
Marianne is frightened by the emergency and worries that it means chemotherapy has failed. She is also concerned about work, independence and the effect on her family.
Evidence
- Expressed fear about treatment failure
- Concern about missing work
- Sudden change from independence to needing help
- Husband is worried and present
- History of depression and regular sertraline
Agreed outcome
Marianne will receive clear, honest information within the team’s role, remain central to decisions and know who to contact after discharge. Emotional and practical concerns will be identified and referred appropriately.
Nursing actions and rationale
- Ask Marianne what she understands and what she wants to know now. Explain that an acute treatment complication does not by itself show whether cancer treatment is working.
- Speak to Marianne first and involve her husband with her agreement. Avoid discussing her care as though she is not present.
- Assess distress, sleep, mood and coping without assuming that all emotion is a symptom of her previous depression.
- Ensure the oncology and Acute Oncology teams address questions about future chemotherapy, dose changes or delays. Do not speculate about treatment decisions.
- Offer referral or signposting to the clinical nurse specialist, psychological support, occupational support, welfare or benefits advice, and other appropriate services according to need.
- Before discharge, reinforce her 24-hour oncology contact route and personalised red-flag advice. Patients receiving systemic anti-cancer therapy should know not to wait for a high temperature if they feel acutely unwell.
- Confirm that medicines, mouth care, hydration advice, follow-up blood tests and review arrangements are understood and documented.
Monitoring and evaluation
Ask Marianne to explain back the key contact and safety information in her own words. Review whether distress is reducing, questions have been answered by the correct team and practical needs have been addressed.
How Marianne remains part of the plan
Marianne has said that her mouth pain is currently her greatest problem, that she wants her husband involved and that staff should speak to her first.
Person-centred care therefore means:
- prioritising the symptom Marianne identifies as most distressing
- involving her in decisions and checking consent before including her husband
- avoiding assumptions about appearance, hair loss or fertility being her main concern
- recognising her work, family roles and usual independence
- explaining uncertainty honestly and referring treatment questions to the oncology team
- using infection precautions without making her feel avoided or blamed
What can the student nurse contribute?
Under appropriate supervision and within competence, a student nurse may contribute by:
- performing and reporting observations and elements of A–E assessment
- recognising deterioration and escalating immediately
- monitoring fluid balance, urine output, stool pattern, mouth condition, pain, skin and bleeding
- supporting prescribed medicines, fluids, electrolyte replacement and investigations according to programme, placement and local requirements
- providing gentle mouth, skin, nutrition and comfort care
- helping Marianne understand what is happening without giving treatment advice outside the student role
- documenting care actually provided and sharing priorities during handover
The registered nurse remains accountable for assessing nursing needs, coordinating and evaluating care, delegating appropriately and responding to deterioration. Diagnosis, prescribing and decisions about cancer treatment are not student-nurse responsibilities.
Evaluation later in the shift
Eight hours after admission, Marianne’s respiratory rate is 18 breaths/min, SpO₂ 97% on room air, heart rate 88 bpm, blood pressure 114/70 mmHg and temperature 37.4°C. Repeat potassium is 3.6 mmol/L following prescribed replacement. She has passed urine and has had no further diarrhoea for three hours. Mouth pain has reduced after prescribed care, and she has managed small sips and a little soft food.
This is encouraging, but the care plan is not complete. Marianne still needs:
- continued neutropenic sepsis monitoring and timely antimicrobials
- review of cultures, stool results and ongoing gastrointestinal symptoms
- fluid-balance, renal-function and electrolyte monitoring
- continued mucositis, pain, nutrition and bleeding assessment
- repeat blood counts and oncology review
- clear 24-hour contact, safety-netting and follow-up arrangements before discharge
The plan must be revised whenever Marianne’s observations, symptoms, blood counts, treatment decisions or priorities change.
Documentation example
“15:40. Care plan reviewed with Marianne following initial treatment for suspected neutropenic sepsis after cycle 2 chemotherapy. RR 19, SpO₂ 97% RA, HR 94, BP 108/66, temperature 37.6°C, GCS 15. Neutrophils 0.4 × 10⁹/L, platelets 95 × 10⁹/L, Hb 9.2 g/dL; repeat potassium awaited after prescribed replacement. One further loose stool documented and specimen sent as requested. Oral mucositis remains painful and limits intake; prescribed analgesia and mouth care given with response to be reassessed. Fluid balance continued. Marianne identifies mouth pain and concern about future treatment and work as priorities. Agrees husband may be involved but requests staff speak to her first. Continue local neutropenic sepsis pathway and escalate any deterioration.”
Documentation must record what was assessed, agreed, provided and escalated. Do not document an intervention before it occurs or copy a generic plan without checking that it applies to the patient.
Reflection questions
- Why does Marianne remain at risk despite improved observations?
- Why would waiting for a temperature above 38°C be unsafe?
- What makes diarrhoea particularly concerning in this situation?
- How should thrombocytopenia affect everyday nursing care?
- How will you know whether mucositis care is helping?
- Which questions must be answered by the oncology team rather than the student nurse?
References and further reading
UK Oncology Nursing Society (UKONS) (2023). Acute Oncology Initial Management Guidelines, Version 4.