Leucopenia 07 (3)

leukopenia and neutropenia

1. LEUKOPENIA & NEUTROPENIA

2. Name-Ashwinee G.C Rollno- 09 Bsc.Nursing 14TH Batch KMCTH

3. C ontents I ntroduction to; leukopenia. neutropenia. enlist the causes of neutropenia. describe the pathophysiology of neutropenia. list the signs and symptoms of neutropenia.

4. Objectives contd… enlist the diagnostic measures of neutropenia. General management describe the medical management of neutropenia. describe the nursing management of neutropenia. prognosis summarize the topic.

5. Introduction White blood cell are also called leukocytes or white corpuscles . All white blood cells have nuclei which distinguishes from other blood cells and platelets .white blood cells are classified into; Granulocytes Agranulocytes These further divided into 5 main types ; Neutrophil Eosinophils (acidophiles) Basophil Monocytes

6. l ymphoctes A healthy human has between 3500-11000/ cubic millimeter.

7. function Granulocytes - They are mediators of allergy and other inflammation . These cells contains other cytoplasmics granules or secretory vesicles ,that harbours potent chemicals in immune responses. Neutroph ils - it contains 50-80 %of cells which is first cells arrive at a site of infection , where they engulf and destroy the infectious microorganisms.(Phagocytosis)

8. 2) Eosinophil s and Basophils Arives at later also called as a mast cells . The granules of basophils and of the closely related mast cells contains a numbers of chemicals ,includings histamines and leukotrines that are important in inducing allergic inflammatory responses. eosinophils destroyes parasites and helps in modulatory inflammatory responses.

9. Agranulocytes 3) Monocytes - it constitute between 4-8% of total no. of wbc , moves from the blood to the sites of infection whereas ,differetiates further into macrophages . - cells are scavengers that phagocytes or killed microrganisms. - direct destruction of pathogens and cleanup cellular debris from sites of infections.

10. 4) lymphocytes Secretes antibodies which are proteins that binds to foreign microrganisms in body tissues and mediate their destruction . T cells- recognize virally infected or cancerous cells and destroys them. -also assist the production of antibody by Bcells . B cells- determines the specificity of immune responses to antigens (foreign substances in body)

11. Leukopenia A reduction in total number of circulating white blood cells having fewer than 3500 wbc per microliter. This may be due to reduction in all type of white cells or in individual cell type (usually neutrophil or lymphocyte) Decreased neutrophil : neutropenia Decreased lymphocyte : lymphopenia Even if other types of leukocytes (eg, monocytes, basophils) are diminished, their numbers are too few to reduce the total leukocyte count significantly.

12. Causes Blood cell or bone marrow conditions Hypersplenism Myeloproliferative syndrome Myelofibrosis Cancer treatment Chemotherapy Radiation therapy Bone marrow transplant -damages the bone marrow

13. Causes contd… Congenital problems Congenital neutropenia (Kostmann syndrome-its rare severe congenital neutropenia disorder characterized by lack of mature neutrophils ANC less than 500cells /mm3 and recurrent bacterial infection Autoimmune disorders SLE - kills white blood cells Medications induced Bupropion,clozapine , immunosuppresant,cyclosporin affects numbers of wbc counts .

14. Neutropenia Neutropenia is a decrease in circulating neutrophils. Neutropenia is characterized by count of neutrophil less than 15,00/mm3 results from decreased production of neutrophils or increased destruction of these cells. Granulocytopenia is defined as a reduced number of blood granulocytes, namely neutrophils, eosinophils, and basophils. However, the term granulocytopenia is often used synonymously with neutropenia

15. The risk of ser ious infection increase absolutes the neutrophils count ANC falls to the severely neutropenic range (500/microltr).T he duration and severity of neutropenia directly corelates with the total incidence of all infections and of those affection that are life threatening .TB is one types of infection that may cause neutropenia.

16. Classification of ANC Neutrophil Generally accepted reference range for absolute neutrophil count (ANC) in adults is 1500 to 8000 cells per microliter (µl) of blood. Three general guidelines are used to classify the severity of neutropenia based on the ANC (expressed below in cells/µl): Mild neutropenia (1000 <= ANC < 1500): minimal risk of infection Moderate neutropenia (500 <= ANC < 1000): moderate risk of infection. Severe neutropenia (ANC < 500): severe risk of infection.

17. A NC Count = Total WBC * %[PMNs +bands] /100 NOTE ; WBC needs to be expressed in 1000 . For eg if the WBC count is 2000 with 65%neutrophils and 5%bands , then the ANC is 1400 which is calculated like this ANC =[(65+5)/100]*2000 =(70/100)*2000 0.7*2000= 1400ans

18. The risk is significant when the ANC is less than 1000/mm3, is high when it is less than 500/mm3, and is almost certain when it is less than 100/mm3. The risk of developing infection also increases with the length of time during which neutropenia persists, even if it is somewhat mild.

19. Causes Decreased production of neutrophils Aplastic anemia, due to medications or toxins Metaplastic cancer, leukemia Myelodysplastic syndromes Chemotherapy Radiation therapy

20. Causes contd… Ineffective granulocytopoiesis Megaloblastic anemia Increased destruction of neutrophil Hypersplenism Chemotherapy (there is formation of antibody to the medications which declines neutrophil count) Immunologic disorder like SLE Viral disease like hepatitis

21. Pathophysiology The pathophysiology of neutropenia can be divided into 2 parts. i.e congenital and acquired Congenital is autosomal dominant , with mutations in the ELA2 gene ( neutrophil elastase ) as the most common genetic reason for this condition.

22. Pathophysiology contd… 2. Acquired neutropenia ( immune-associated neutropenia) is due to anti-neutrophil antibodies that target neutrophil-specific antigens, ultimately altering neutrophil function.

23. Clinical manifestations Low grade feve r- Patients with neutropenia often do not exhibit classic signs of infection. Fever is the most common indicator of infection, yet it is not always present, particularly if the patient is taking corticosteroids Odynophagia -(difficulty in swallowing ) b Gingival pain and swallowing Recurrent sinusitis and otitis Symptoms of pneumonia (like- cough, dyspnea ) Perirectal pain and irritation

24. Clinical manifestations contd.. Stomatitis Periodontal infection Cervical lymphadenopathy Skin infection: rashes, ulcers or abscesses Splenomegaly Associated petechial bleeding Perirectal infection Growth retardation in children

25. Diagnostic measures History taking - determine major causes and family history. Physical examination - asses the sinusities ,skin lession , gums ,lymphadenopathy bleeding and assculate the breath sounds ,palpate the spleen. , Complete blood count : agranulocytosis( ANC) Differential white blood cell count Peripheral smear Liver function test

26. Serum immunoglobulin studies Antinuclear antibodie s – positive in SLE Antineutrophil antibodies: Tests for antineutrophil antibodies should be performed in patients with a history suggestive of autoimmune neutropenia and in those with no other Rheumatoid factor – positive in RA Monitor all cultures and sensitivity reports. X-rays Monitor globulin myoglobin and total protein levels.

27. Medical management Depends upon cause. Medication induced: stop the medication …….. - Withhold chemotherapy Treatment of an underlying neoplasm can temporarily make the neutropenia worse, but with bone marrow recovery, treatment may actually improve it. If fever, admit to hospital as it is a sign of infection Corticosteroids and IV Ig if immunologic disorder Use of growth factors such as granulocyte colony- stimulating factor (G-CSF) or granulocyte macrophage colony stimulating factor increases neutrophil production G-CSF 1-10 mcg/kg/day SC

28. Medical management contd… Reducing the dose of chemotherapy or radiation therapy may be required if caused by these therapy Broad spectrum antibiotics for infection Cephalosporin 250-500 mg QID for 7-14 days.

29. Surgical management splenectomy T he person who have recurrent life threatening bacterial infections,splenectomy is the treatment of choice . splenectomized pts had a 2-3 folds increased risk of pneumococcal pneumonia other meningitis …. had showed antibody decreased in immunocompromised.

30. G eneral Management Remove any offending drugs or agents in cases involving drug exposures .if the identity of the causative agent is not known , stop administration of all drugs until etiology is established. use careful oral hygiene to prevent infection of the mucous and teeth . Avoid rectal temperature measurement and rectal examination . Administer stool softeners for constipation. use good skin care for wounds and abrasions ;skin infection should be managed by someone with experience in the treatment of infection in neutropenic patients.

31. Nursing management Nursing assessment History taking Physical examination - skin for tenderness ,edema breaks in the skin integrity moisture drainage , lesions , all punctures sites . Review of laboratory tests (blood counts, peripheral smear, antibodies study ) -monitor globulin ,total protein levels, and monitor all cultures and sensivity reports

32. Nursing Diagnosis Risk for infection secondary to impaired immunocompetence due to; Diminished neutrophil count secondary to bone marrow invasion or hypocellularity secondary to decrease or treatment. dysfunctional lymphocytes surgery or invasive procdure malnutrition Antibiotics therapy ( increased risk of superimposed infection)

33. Nursing Intervention Prevent infection Thorough hand hygiene must be performed before touching patient. and oral hygiene after mealswith salt or oral solutions. verbalize the reason for the infection identify the signs and symptoms of infection . Avoid the patient with over crowds and infections. Monitor for signs and infections. Iv therapy Avoid plastic cannulas for peripheral IVS when ANC is less than 500/mm3 if possible ; a central vascular acess devices prefered for long term .

34. 2.. maintain meticulous IV site care. 3. moisture vapor permeable dressing are permissible with strict adherences to institutional protocol. 4. change IV tubing per institution policy using aseptic techniques . 5. Administer antimicrobial agents on time.

35. Avoid suppositories enemas ,rectal temperatures. practices deep breathing with incentive spirometry every 4 hourly while awake . Ambulate ;wear high efficacy mask if neutropenia is severe. prevent skin dryness with lubricants in especially high risks areas eg. lip corner of mouth , elbows, feet ,bony prominences .

36. Nursing management contd… Neutropenic / immunocompromised diet Foods to be avoided All uncooked vegetables , eggs raw meats , fruits . Encourage for adequate hydration.

37. Nursing management contd… Expected outcomes Restore neutrophil count Prevent destruction Prevent infection by abscence of fever,dyspnea ,cough .

38. Prognosis The prognosis is good with the a benign courses. however 10% of patients will experiences life threatening infections.

39. MCQS If the WBC count is 2,000 with 75% neutrophils and bands 5% then ANC is……. 1350 1400 2100 1500

40. Neutropenia is decreased in circulating neutrophils less than 15,00/mm3 5000/mm3 4400/mm3 1000/mm3

41. Assignments Write the complication and epidemiology about the neutropenia

42. References Smelzer. S.C. et. Al. (2009). Brunner and Suddarth’s Textbook of Medical Surgical Nursing. 11 th edition. India: Wolters India Pvt. Ltd. Page no. 918-923 Black. J.M. Hawks. J.H. (2009). Medical Surgical Nursing. 8 th edition. India: Elsevier. Page no. 1878- 1880 Sandra. M. et. Al. (2007). Lippincott Manual of Nursing Practice. 8 th edition. India: Jaypee Brothers Medical Publishers Pvt. Ltd. Page no. 996-998

43. Retrieved from https://www.nrsng.com >care-plan https://www.emedicinehealth.com https://en.m.wikipedia.org https://www.cancer.net https://www.mayoclinic .org https://www.aaai.org .