Learning Objectives
By the end of this section, you will be able to:
- Discuss the pathophysiology, risk factors, and clinical manifestations associated with neutropenia
- Describe the diagnostics and laboratory values in neutropenia
- Apply nursing concepts and plan associated nursing care for the patient with neutropenia
- Evaluate the efficacy of nursing care for the patient with neutropenia
- Describe the medical therapies for neutropenia
A medical condition marked by abnormally low levels of neutrophils is called neutropenia. WBCs play an integral part in our immune system’s defenses against pathogens. A neutrophil is a type of WBC that helps fight against bacteria and fungi. Neutrophils make up most of the WBC populations in the human body: normally, there are up to 8,000/μL of a whole-blood sample (Yale Medicine, n.d.). Someone with mild neutropenia has WBC levels of 1,000–1,500/μL; moderate neutropenia is characterized by WBC levels of 500–1,000/μL, and severe neutropenia by WBC levels below 500/μL (Yale Medicine, n.d.).
Consider the WBCs as the soldiers in the body’s army against common pathogens like bacteria and fungi. When the body recognizes invading pathogens, it releases WBCs into the area to attack, engulf, and destroy them. A WBC count higher than 11,000/mm3 demonstrates the body is fighting an infection, whereas a WBC below 4,000/mm3 may mean there are no more WBCs left to fight, leaving the body without protection and at risk for a dangerous infection. Nursing assessment and medical treatments are then needed.
Pathophysiology of Neutropenia
There are many causes of neutropenia, including chemotherapy, which suppresses bone marrow production of neutrophils. Certain antibiotics and antiseizure medications can also decrease the number or effectiveness of neutrophils. Cancer, tumors, and conditions such as aplastic anemia and myelodysplastic syndromes can hinder the bone marrow’s ability to produce neutrophils, and certain infections, such as HIV, can decrease neutrophil levels. Autoimmune disorders, such as lupus and rheumatoid arthritis, can mistakenly attack neutrophils, leading to neutropenia. Without adequate amounts of neutrophils, the body is at risk of further infections.
Types of Neutropenia
Classifying neutropenia assists health-care providers in understanding its cause, forecasting its progression, and deciding on appropriate interventions. The following types of neutropenia are defined based on their respective causes:
- Autoimmune neutropenia is when the immune system mistakenly attacks and destroys neutrophils, leading to low neutrophil counts.
- Chronic idiopathic neutropenia is characterized by persistently low neutrophil counts without apparent cause.
- Congenital neutropenia is present at birth and is generally due to a genetic mutation in the bone marrow, where blood cells are created.
- Cyclic neutropenia is a form of neutropenia in which individuals experience regular, cyclic fluctuations in their neutrophil counts; a complete cycle typically happens every 21 days.
- Drug-induced neutropenia is caused by certain chemotherapy drugs and antiseizure medications such as carbamazepine. Other drugs, such as certain antivirals, antibiotics, and antipsychotics also can have an impact.
- Infectious neutropenia is caused by the body’s normal response to external pathogens.
- Post-transplant neutropenia is a side effect of immunosuppressive medications taken after organ or stem cell transplant.
- Secondary (acquired) neutropenia is caused by another condition such as a bacterial, fungal, or viral infection. Underlying conditions may be HIV, hepatitis, cancer, aplastic anemia, or autoimmune diseases.
Treatment and management strategies depend on identifying the specific type and addressing underlying causes whenever possible.
Link to Learning
The Immune Deficiency Foundation provides more information about the diagnosis and treatment of chronic neutropenia on this website.
Clinical Manifestations
Symptoms include traditional characteristics of any infection, such as fever, fatigue, sore throat, swollen lymph nodes, ulcers in the mouth or anus, pain, swelling at an infection site, diarrhea, and dysuria if a bladder infection is present.
Diagnostics and Laboratory Values
A common test to identify the body’s neutrophil level is a CBC count. Additional tests may include a bone marrow sample to identify cell growth and features. Identifying the cause of infection may require additional blood tests, as well as diagnostic radiography. A comprehensive physical exam and complete history can also help identify causes of infection or exposure that may have caused the neutrophil disorder. If there is high degree of suspicion for neoplastic (tumor related) causes, a bone marrow biopsy may be warranted.
Nursing Care of the Patient with Neutropenia
Patients with neutropenia require close nursing supervision to reduce infection risks and promote overall well-being. Close cooperation between all members of the health-care team and patient education are also integral parts of effective nursing interventions for neutropenia management (Yale Medicine, n.d.).
Recognizing and Analyzing Cues
By completing the normal nursing duties of obtaining a health history and completing a thorough physical exam, the nurse can optimize care for a patient with neutropenia. Subjective data may include fatigue, sore throat, pain, and urinary symptoms such as urgency and frequency. Objective data may reveal signs of infection such as fever, swollen lymph nodes, mouth ulcers, rash, and inflammation. Assessing nutritional status may help the nurse evaluate any nutritional deficiencies that may contribute to neutropenia. Diets that are deficient in folate and vitamin B12 may lead to neutropenia (Yale Medicine, n.d.). A CBC count will reveal low WBC levels.
Prioritizing Hypotheses, Generating Solutions, and Taking Action
Acute neutropenia requires hospitalization to avoid further risks of infection. To reduce infection transmission, patients are typically given their own room, a positive pressure isolation room if available, and placed on reverse precautions, also known as neutropenic precautions, which are measures to avoid introducing additional pathogens to the patient, such as:
- Fresh flowers are avoided to decrease exposure to chemicals or Aspergillus fungi infection.
- Fresh fruit and uncooked meats are avoided to avoid foodborne contaminants.
- Meticulous hand hygiene and upholding aseptic techniques all are directed at reducing nosocomial infection.
- Providers, staff, and visitors wear masks to protect the patient from opportunistic infections.
- Routine surveillance of temperature, monitoring absolute neutrophil counts, and thorough skin assessments are performed to help identify the source of an infection or signs of a potentially worsening infection.
- The nurse educates the patient to use good oral and pulmonary hygiene to avoid oral fungal infections and nosocomial pneumonia.
To optimize immune functioning, adequate hydration and protein in nutrition are instrumental. Administration of antibiotics, antivirals, and corticosteroids may be necessary. Although neutropenia places patients at risk for bacterial infections, perpetual drops in WBC count and other aspects of immunity place patients at risk for pancytopenia, which is a reduction in platelets, RBCs, and WBCs.
Evaluation of Nursing Care for the Patient with Neutropenia
Evaluation of nursing interventions for neutropenia involves observing how patients react to care, monitoring for any indications of improvement, and making necessary modifications as required. For every nursing intervention, the nurse must evaluate the patient’s response to the intervention for effectiveness as part of the nursing process (Yale Medicine, n.d.). Table 16.5 describes how common nursing interventions for neutropenia should be evaluated.
| Nursing Intervention | Evaluation |
|---|---|
| Regularly monitor neutrophil count | Assess for trends and notify provider of progress or decline. |
| Assess signs and symptoms of infection | Assess for fever, infection, fatigue, and signs of inflammation. |
| Monitor vital signs | Evaluate stability of blood pressure and temperature. Document findings to recognize trends. |
| Observe skin and mucous membranes | Evaluate skin integrity and protect skin as needed to prevent breakdown. Assess for petechiae, ecchymosis, and pancytopenia. |
| Patient education | Instruct patient about the importance of adhering to medication orders and hand hygiene. Instruct patient how to practice hand hygiene. Address any barriers to understanding. |
| Neutropenic precautions: hand, oral, and respiratory hygiene | Evaluate staff and family adherence to neutropenic precautions and re-educate as needed. Provide needed supplies and signage. |
| Collaborate with health-care team | Evaluate team’s ability to communicate and support the plan of care. Address any barriers to understanding. |
| Administer prescribed medications | Evaluate the patient’s response to medications by monitoring the WBC count. Take precautions to avoid side effects or adverse reactions. |
Medical Therapies and Related Care
Therapies should be focused on stimulating WBC creation to replace and recover healthy neutrophils. Classifying neutropenia helps health-care providers better comprehend its cause, predict its course, and tailor interventions accordingly. Treatment and management strategies entail identifying each specific type while targeting any possible root causes underlying it (Yale Medicine, n.d.). Regular blood count monitoring as well as cooperation among health-care providers are integral for successfully treating neutropenic conditions.
Antibiotic treatment can directly fight many bacterial and fungal pathogens. Corticosteroids can help suppress the body’s immune response if the neutropenia is caused by an autoimmune condition that destroys the body’s own WBCs. Medications to stimulate neutrophil genesis in bone marrow include filgrastim. Granulocyte colony-stimulating factor medications promote WBC production in the bone marrow. Antithymocyte globulin is an immunosuppressant that may be used to treat neutropenia from aplastic anemia. A bone marrow or stem cell transplant may be performed if the underlying cause of neutropenia is a condition such as aplastic anemia or leukemia. Additionally, implementing reverse precautions can protect the patient from further infection during treatment.