Neutropenia: Nursing

Neutropenia refers to an abnormally low number of neutrophils in the blood. Normally, neutrophil count ranges from 2500 to 7500 neutrophils per microliter, but with neutropenia, it’s usually less than. 1500 neutrophils per microliter of blood. Remember that neutrophils are a subtype of white blood cells that fight off bacterial and fungal infections, so with neutropenia, individuals are at higher risk of developing these infections.

Let’s start with some basic physiology of neutrophils. These cells are created in the bone marrow, from hematopoietic stem cells, which give rise to all types of blood cells. Now, once neutrophils are formed, they leave the bone marrow and enter the bloodstream, where they have an important role in the innate immune response against bacterial and fungal pathogens. Specifically, they fight foreign pathogens by phagocytosis, which is a process of ”ingesting” them into the cell. And next, they digest them inside the cell!

Ok, now, neutropenia can be caused by conditions like infections, when neutrophils are used up faster than they can be produced; as well as autoimmune conditions like systemic lupus erythematosus, which is associated with increased neutrophil destruction. Alternatively, neutropenia can occur because of inefficient bone marrow production, which can be seen in hematologic conditions like aplastic anemia or leukemia. Finally, neutropenia can occur because of an infection that weakens the immune system, such as AIDS; or as a side effect of some medications, including antibiotics like carbapenems and cephalosporins; and chemotherapeutic agents, which are medications used to treat cancer.

Now, with fewer neutrophils in the blood, the immune system can’t fight infections effectively, and this results in recurrent infections. The most common bacterial infections are caused by Staphylococcal, Streptococcal, and E. coli species, while the most common fungal infection is caused by Candida albicans. Finally, even though the overwhelming majority of infections in neutropenia are caused by bacteria or fungi, some viral infections, like herpes simplex or herpes zoster, also occur more frequently with neutropenia. Finally, it's important to note that these infections can cause life-threatening complications, such as sepsis, septic shock, or even death.

Ok, now, the clinical manifestations of neutropenia are usually absent until a person develops an infection, most commonly an infection of the gingiva, pharynx, lungs, eyes, and skin. In other words, clinical manifestations depend on the site of infection. For example, clients with periodontal infections develop redness, swelling, and bleeding of the gingivae; while individuals with pharyngeal infections typically complain of sore throat. Pulmonary infections usually cause cough and shortness of breath; while eye and skin infections are most commonly associated with local pain and redness.

Diagnosis of neutropenia starts with the client's medical history and physical assessment. A CBC typically reveals leukopenia, or a low number of all white blood cells, as well as neutropenia, or an absolute neutrophil count (ANC) less than 1500 per microliter of blood. In mild neutropenia, absolute neutrophil count ranges from 1000-1500; while in moderate neutropenia, it ranges from 500-1000. Finally, severe neutropenia is characterized by less than 500 neutrophils per microliter.

Other tests include microbiological cultures from the infection site, which can reveal the causative pathogen and its sensitivity to antibiotics. In severe cases, a blood culture should be obtained to exclude bacteremia and prevent life-threatening complications. Finally, other investigations can be done to identify the cause. For example, different serum antibodies can be determined to identify an autoimmune condition, like antinuclear antibodies when systemic lupus erythematosus is suspected; or a bone marrow biopsy when leukemia or aplastic anemia are suspected.

Now, treatment of neutropenia starts with treatment of the current infection with wide-spectrum antibiotics or antifungals. Additionally, hematopoietic growth factors called G-CSFs or GM-CSFs can be used to stimulate the production of neutrophils. These can be used in the treatment of autoimmune neutropenia, as well as for prophylaxis during chemotherapeutic treatments.

Alright, let’s look at the nursing care you’ll be providing for a client with neutropenia. Your priority nursing goals are to reduce infection risk and monitor the client for the development of new infections.

Now, if your client has severe neutropenia, place your client in a private room and institute neutropenic precautions. Enforce strict hand hygiene protocol and screen all staff members and visitors for signs of infection. Also be sure to assess their IV sites for signs of infection. To protect your client from exposure to potential sources of pathogens, prohibit live plants or flowers and order a neutropenic diet that’s high in protein and calories, and does not include raw fruits, vegetables, and uncooked meats. Also change their bed linen daily, keep it dry and wrinkle-free, and cleanse the skin with the appropriate antimicrobial solutions as ordered.