Complexity Is the Cornerstone of BMT Nursing

October 07, 2019 by Addi Watters MSN, RN, AGPCNP-BC, OCN®, BMTCN®

By Addi Watters, RN, OCN®, BMTCN®

Addi Watters, RN, OCN®, BMTCN®
Addi Watters, RN, OCN®, BMTCN®

You’re juggling three patients: one is nauseated and requesting lorazepam now, another’s blood transfusion is finished and the pump’s alarm is loudly chirping down the hall, the third has an order list coming in like rapid fire—and it’s only 8 am. In a blood and marrow transplant (BMT) unit, this sounds like a relatively calm morning.

As a nurse, no matter what specialty you work in, you’re undoubtedly pulled in many directions, stretching yourself so much you probably put Gumby to shame. Nurses must know how to manage complex situations and countless patient requests, and the BMT population is no different. 

Managing Transplant Complications

The immediate post-transplant period is one of the most critical patient times, especially if they’re neutropenic. Although most oncology nurses are aware of how to manage neutropenia, the complexity compounds when patients develop severe complications such as mucositis, sepsis, or acute kidney injury (https://www.ncbi.nlm.nih.gov/pubmed/26415560). These are common among BMT recipients and can be life threatening. Swift, effective nursing care is vital for positive patient outcomes.

But what happens when a patient develops all three potential complications—and you still have to manage caring for all your other patients? BMT nurses must master the art of time management and prioritization. Thinking about what medications are compatible with each other, determining whether a patient in need of physical therapy is stable enough, and attempting to attend rounds so you can hear what the plan is for the day all must be managed concurrently in BMT nursing. Knowing which aspects of care to prioritize helps to keep the workflow manageable while also ensuring you’re providing the best possible care to your patients.

Remaining Vigilant for Vulnerable Patients

A BMT nurse’s knowledge of transplant complications like neutropenic sepsis is hugely beneficial for patient well-being—both during the complication and for the rest of the patient’s life. Nursing assessment during neutropenia can prevent long-term issues and is an essential part of caring for this unique patient population.

Allogeneic transplant recipients are sometimes required to be off their calcineurin inhibitors, such as tacrolimus or cyclosporine, because of the risk of acute kidney injury (https://www.nature.com/articles/bmt2015357). But those patients still need immunosuppression to prevent graft-versus-host disease, and the medication of choice is steroids (https://www.ncbi.nlm.nih.gov/pubmed/26415560). While patients are on steroids, they may not exhibit typical signs of infection (https://www.ncbi.nlm.nih.gov/pubmed/26415560) like running a fever. Because BMT nurses are at the forefront of transplant care, we’re able to monitor for changes in clinical status like tachypnea and altered mental status—signs of sepsis (https://link.springer.com/article/10.1007/s00277-019-03622-0). I’ve seen many patients on steroids exhibit these signs, as well as being afebrile or neutropenic, only to later find them septic. Patients should be placed on surveillance blood cultures (https://www.ncbi.nlm.nih.gov/pubmed/26415560) to watch for a potential bloodstream infection, and a BMT recipient on steroids while neutropenic requires vigilant nursing care. 

Championing Patient Care

All nurses are advocates for their patients. As I’ve progressed in my career, I have learned to trust my instincts. I may not always have the answers or know exactly what’s wrong with my patient in the moment, but I know what is abnormal and when to report it. As lifelong learners, it’s our jobs to evolve and grow in our practice.

Some days can pull you in many different directions—but remember you’re not Gumby—you’re better! You’re an oncology nurse, and you thrive on being tasked with countless responsibilities and managing complex patient cases while being the best nurse to the patients relying on you. That’s the hallmark of BMT nursing—and of all oncology nursing too.


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