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Leukocytes / Neutrophils / Eosinophils / Basophils / Monocytes
Lymphocytes / Natural killer cells / Complement / Rheumatoid factor
Culture & sensitivity / ERS / C-reactive protein / Antinuclear antibodies
Cold agglutins / Therapeutic drug monitoring

Objectives:

1. Discriminate between total and differential WBC counts.

2. Be able to calculate total WBC and each cell line.

3. Describe the major function(s) of each cell line.

4. Identify critical values for WBC, neutrophils and lymphocytes.

5. Discuss differences between cellular and humoral immunity.

6. Identify significance of neutrophil shifts to right or left.

7. Compare nursing care of patient with leukopenia and neutropenia.

8. Describe the most common causes of neutropenia, neutrophilia, eosinophilia, eosinopenia, basophilia, basopenia, monocytosis, lymphocytosis, lymphocytopenia.

9. Compare the function of B and T lymphocytes.

10. Describe the importance of the lymphocyte CD4 count and viral load.

11. What is the function of the plasma cell and natural killer cell.

12. Format a  plan of care for a patient with lymphocytopenia.

13. Which lymphocyte does immunosuppressive drugs target?

14. What is the significance of the sensitivity portion of the culture and sensitivity?

15. What does an elevated erythrocyte sedimentation rate indicate?

16. What is a titer?

17. What is the importance of a drug peak and trough? When are the samples taken?

Leukocytes (WBC)

WBC are measured to test the ability to respond to infection, confirm presence of infection, help to tell type of infection, monitor response to treatment for infection, monitor for side effects of therapy, and monitor for complications of illness

There are two types of cells:
Myeloid - made in bone marrow. Includes granulocytes (neutrophils and bands, basophils, eosinophils) and monocytes.
Lymphoid: made and stored in lymph tissue. Includes lymphocytes.

We have two methods of measuring WBCs: total count and differential
    

 Critical Values

WBC < 2000 or > 30,000
Lymphocytes < 500                     (this is an absolute number)
Neutrophils < 500                      (this is an absolute number)

 Absolute cell count = % of cells X WBC

   For example:

WBC = 6000              Neutrophils = 60%
Bands=  2%                Basophils =  1%
Eosinophils = 2%       Monocytes = 5%
Lymphocytes = 30%

 Calculate the absolute count of each. 

v  Neut     =     6000 X .60 = 3600
v  Bands   =     6000 X .20 =   120
v  Baso     =     6000 X .10 =    60
v  Eos       =     6000 X .20 =  120
v  Monos  =     6000 X .10 =     60
v  Lymphs  =    6000 X .30 = 1800
                                  total  =  6000

  
Types of Immunity

Cellular immunity involves the following cells: T lymphocytes, monocytes, neutrophils
Humoral immunity involves antibodies formed by B lymphocytes. Several types of humoral immunity occurs. The primary response involves the antibodies IgG and IgM. The secondary response begins immediately and results in long term recognition of specific antigens.

 Leukocytosis - WBC > 10,000

Usually only one cell type is increased. If all cell types are increased, consider hemoconcentration. Leukocytosis occurs only in acute infections. In chronic infections, you may have high WBC but usually not above 10,000.

Causes of leukocytosis: Myeloproliferative diseases, leukemia, trauma or tissue injury, malignant neoplasms (esp. bronchogenic cancer), acute hemolysis, issue necrosis, toxins (uremia, coma, eclampsia, thyroid storm), drugs, acute hemorrhage, after splenectomy, polycythemia vera.

Leukocytosis is sometimes found without evidence of disease: Sunlight, ultraviolet irradiation, physiologic leukocytosis (excitement, stress, exercise, pain, heat or cold, anesthesia), nausea & vomiting, seizures, steroid therapy. ACTH causes leukocytosis in healthy person. ACTH masks leukocytosis in persons with severe infection .

Leukopenia -  WBC < 4000/mm³ 

Causes of leukopenia: Viral infections, some bacterial infections, overwhelming bacterial infections, hypersplenism, bone marrow depression, primary bone marrow diseases, immune-associated neutropenia, diseases occupying the bone marrow, iron deficiency anemia. 

Nursing care of the patient with leukopenia 

1. Protect the patient from infections 
2. Avoid crowds
3. Avoid persons with colds, flu, or cold sores
4. If reverse isolation is necessary, check temperature every 4 hours
5. No plants or cut flowers in room 
6. Eat only cooked vegetables
7. Evaluate daily for signs of urinary tract infections
8. Encourage pulmonary hygiene 

WBC Differential: there are 5 types of WBCs. The differential can tell you what type of infection is present.

Neutrophils

Also called PMNs, segs or polys .
Normal is 50-60%; absolute cell count 3000-7000
Neutrophils are the first cells to enter infected area. Their primary function is phagocytosis. Bands or stabs are immature neutrophils (1-3%). The life span is 6 hours.

  Neutrophilia - Relative percent  >70%; absolute neutrophils > 8000

Causes of neutrophilia: acute bacterial infection, inflammation, metabolic or chemical poisoning, acute hemorrhage, acute hemolysis, myeloproliferative diseases, tissue necrosis, early stages of some viral diseases.

 Interfering factors: stress, excitement, fear, anger, joy & exercise temporarily cause neutrophilia. Crying babies have neutrophilia.
Labor & delivery, menstruation causes neutrophilia. Children have greater neutrophilic response than adults. Some elderly patients have little or no neutrophilic response. People of any age who are debilitated, may not have neutrophilic response.
Number of neutrophils decrease greatly with overwhelming infection, resistance exhausted, approaching death.

Ratio of segs to bands

Shift to left  ß  Increased bands  Means acute infection, usually bacterial.
Shift to right à  Increased mature cells

Degenerative shift to left : Overwhelming infections, increase in bands without leukocytosis
Regenerative shift to left: Increase in bands with leukocytosis, bacterial infections,   Good prognosis
Shift to right: Few bands with neutrophilia, liver disease, megaloblastic anemia, hemolysis, drugs, cancer, allergies
Hypersegmentation without bands: Pernicious anemia, chronic morphine addiction

Neutropenia
Absolute count < 1800 in Caucasians, < 1000 in African-Americans
Relative percent < 40%
< 5000 in neonates or < 1000 in infants

Causes of neutropenia: acute overwhelming bacterial infection, viral infections, rickettsail diseases, some parasites, drugs, chemicals, toxic agents, radiation, blood diseases, anemias, hormonal disorders, anaphylactic shock, renal disease, autoimmune diseases, hypersplenism.

Agranulocytosis (marked neutrophenia & leukopenia) is dangerous. Body is unprotected against invading agents. Requires reverse isolation.

Nursing care of the patient with neutropenia.

1. Instruct patient/significant others of potential for high risk, life threatening infection to promote compliance
2. No plants or cut flowers in room
3. Keep room clean and free of clutter, keep bathroom and sink area especially clean
4. No rectal temps or medication
5. The patient should have their own equipment - blood pressure cuff,  thermometer etc..
6. Patient should wear a mask when outside of room
7. Absolutely no contact with anyone who has an active infection (i.e.. Nurse must only care for other clean patients)

This site discusses the granulocytes (neutrophils, eosinophils and basophils): http://www.proiris.com/clinfx/hemat/hematpri/granulo.htm

Eosinophils     

Concentrated in respiratory tract and GI tract. Activated by allergic reactions, foreign proteins and parasites. Diurnal rhythm – lowest in morning. Stress (physical or emotional) decreases count. Eosinophils disappear with corticosteroids.

Eosinophilia -  > 500 or > 5%
Causes of eosinophilia: Allergies, asthma, parasitic diseases, Addison’s disease, hypopituitarism, myeloproliferative disorders, immunodeficiency disorders, chronic skin disorders, pulmonary infiltration, some infections (scarlet fever, chlamydia), collagen & connective tissue disorders, drug reactions, aspirin sensitivity.
This site provides extensive information about eosinophilia:
http://www.postgradmed.com/issues/1999/03_99/brigden.htm

Eosinopenia
Causes: Usually caused by increased circulating steroids, Cushing’s syndrome, drugs (ACTH, epinephrine, thyroxine, prostaglandins), acute bacterial infections with a shift to left.  Eosinophilic myelocytes found only in leukemia or leukemoid pictures.

 Basophils

Concentrated in connective tissue and pericapillary areas. Release heparin, bradykinin, serotonin and histamine. Mediate allergic reactions. Help keep inflammatory substances at site.

Causes of basophilia: Myelocytic leukemia, inflammation, allergy, sinusitis, polycythemia vera, chronic hemolytic anemia, after splenectomy, after ionizing radiation, hypothyroidism, foreign protein ingestion, infections (TB, smallpox, chickenpox, influenza)

Causes of basopenia: stress reactions, hyperthyroidism, prolonged steroid therapy, chemo, radiation, acute rheumatic fever, acute phase of infection in children.

Monocytes

Mature form is macrophage. Function in blood like macrophages do in tissue.

Macrophages
Macrophages are not measured because they are found in tissue, especially GI tract, lungs, skin, spleen. First cells to pick up foreign organisms that enter by routes other than blood. Essential for immune system to work. They process foreign material and present it to other cells. They also produce interleukin 1 (IL-1).

Causes of monocytosis: Bacterial infections, Tuberculosis, Subacute bacterial endocarditis, Monocytic leukemia, Myeloproliferative diseases, lymphoma, Recovery of neutropenia, Lipid storage diseases, Parasitic and rickettsial diseases, Collagen diseases, Surgical trauma, Ulcerative colitis, enteritis, sprue, Tetrachlorethane poisoning

Causes of monocytopenia: Prednisone treatment, Hairy cell leukemia, Overwhelming infection causing neutropenia, HIV

 Lymphocytes

This site provides in-depth information about B and T cells:
http://www.ultranet.com/~jkimball/BiologyPages/B/B_and_Tcells.html

T-lymphocytes are major fighters against viral, fungal, protozoa, and some bacteria; and provide surveillance against cancer. CD₄ cells produce IL-2 and other interleukins.
 B lymphocytes respond to processed organisms. They are transformed to plasma cells. Functions include identifying antibodies (immunoglobins) in blood, fighting bacteria and other organisms.
*Good B-cell function requires good T-cell function.

Causes of lymphocytosis: Lymphatic leukemia, infectious lymphocytosis, infectious mononucleosis, CMV, measles, mumps, chicken pox, toxoplasmosis, viral URI, infectious hepatitis, TB, pertussis, Crohn’s disease, ulcerative colitis, hypoadrenalism, Addison’s disease, thyrotoxicosis, serum sickness, drug hypersensitivity

Causes of lymphopenia: Chemotherapy, radiation, ACTH- producing tumors, steroid administration, aplastic anemia, obstruction of GI lymphatic drainage, Hodgkin’s disease, other malignancies, inherited or acquired immune disorders, advanced TB, severe debilitating illness of any kind,   CHF, SLE, renal failure

 CD4

Decreased: Immune dysfunction, AIDS, acute minor viral infections
Increased : Therapeutic drug effect, diurnal variation – peak in evening 2 times morning level.

Plasma cells
Mature B-lymphocytes that produce antibodies.
Increased: Plasma cell leukemia, Hodgkin’s disease, multiple myeloma , cirrhosis, chronic lymphatic leukemia, rheumatoid arthritis, cancer (liver, breast, prostate), SLE, serum reaction, some bacterial, viral or parasitic infections

Interfering factors: Stress, exercise, menstruation cause lymphocytosis. African Americans have a relative (not absolute) increase in lymphocytes.

Natural Killer Cells
Unique lymphocytes with cytotoxic ability. Involved in all types of defense. They work in conjunction with T lymphocytes

Special measures of lymphocytes
CD - cluster differentiation  - based on markers on cell membrane

CD3   (total T-lymphocytes > 1500)
CD4   (helper/inducer  500-2200 cells/ul)
CD8   (suppressor/cytotoxic [CD3⁺] cells)
CD4 : CD8     normally in 2:1 ratio
CD19  (B cells)
CD25  (activated T cells [CD3⁺] )
CD45  (panleukocytes)
CD16 (natural killer cells)
T-cells panel - combination of various groups, such as CD45, CD3, CD8, CD25, CD56, CD19
T-helper/T-suppressor ratio  > 1.0

 Nursing considerations:

• Lymphocyte measures vary across labs.  
• vary diurnally. 
• Draw in am
• Don’t let sit overnight.

 Lymphocytopenia

v Opportunistic infections frequently occur during lymphopenia.
v Prednisone can decrease T lymphocytes
v Major finding in AIDS is decreased CD₄ ;   < 200 = AIDS
v If T lymphocytes < 2000 look for signs of malnutrition
v  Decreased T lymphocytes occur in transplant patients 
     receiving immunosuppressant drugs

 Management of patients with low lymphocytes

v  No fresh fruits or vegetables, cooked food only
v  All food must be served from new or single-serving package
v   No IM injections
v  No rectal temps, suppositories, enemas
v  No aspirin or NSAIDs
v  Monitor temperature

 Antibodies
IgA = lungs, skin, GI infections
IgG = Generalized bacterial infection

Complement
Increased in acute response to inflammation or infection
Absent in hypercatabolism (autoimmune), hereditary deficiency and overexpenditure of complexes
Used to monitor or evaluate SLE

Leukemia
Classified by course and duration - Acute or chronic
Classified by cell type - Myeloid (granulocyte), Moncytic, Lymphocytic

Culture and Sensitivity

Antibiotic sensitivity testing detects type and amount of antibiotic required to inhibit bacterial growth. Frequently use disc method where antibiotic impregnated discs placed on agar innoculated with bacteria. Degree of inhibitions of bacterial growth indicates effectiveness of antibiotic.

• Sensitive and susceptible imply that antibiotic will inhibit or kill     organism

• Intermediate, partially resistant, moderately susceptible indicates     organism not completely inhibited by therapeutic doses

• Indeterminant – may be susceptible to high doses

• Resistant – organism not inhibited

 Types of cultures

Aerobic
Anaerobic
Fungal
Acid fast

Get cultures before antibiotics started. Can use special procedures if antibiotics already started.
Gram stain is used to identify if specimen is good and as initial basis for therapy.

 Parasites are seen visually.

Immunological Studies

Tests for disorders of immune function

Erythrocyte Sedimentation Rate (ESR, sed rate)  

Nonspecific test for inflammation
Inflammatory and necrotic processes alter plasma proteins which cause agglutination of RBCs and they settle faster
Used to monitor treatment for temporal arteritis, rheumatoid arthritis, polymyalgia rheumatica

Increased ESR: All collagen diseases, infections, inflammatory diseases, all cancers, acute heavy metal poisoning, cell or tissue destruction, toxemia, nephritis, nephrosis, subacute bacterial endocarditis, anemia, rheumatoid arthritis, gout, arthritis
Extreme elevations found in  malignant lymphocarcinoma of colon or breast, myeloma, and rheumatoid arthritis 

Interfering factors: Refrigerated blood, pregnancy after 12 weeks until 4 weeks postpartum, young children, menstruation, anemia, hyperglycemia, hyperalbuminemia, decreased fibrinogen in newborns, polycythemia or high Hgb, drugs: steroids, aspirin, heparin, oral contraceptives

 C-Reactive Protein (CRP)

Normal < 0.8 mg/dl
Nonspecific
Used to evaluate inflammatory disease management and severity of diseases which cause tissue necrosis

Positive CRP: rheumatic fever, rheumatoid arthritis, myocardial infarction, malignancy, acute bacterial & viral infections, postoperatively

Antinuclear Antibodies
Normal is negative by immunofluorescence; titers done if positive (<1:160 normal)
Used in differential diagnosis of rheumatoid diseases: SLE, lupoid hepatitis, scleroderma, rheumatoid arthritis, Sjogrens disease, dermatomyositis, polyarteritis
Subtypes of ANA
        Anti-dsDNA antibody
        Antibodies to extractable nuclear antigens
        Anti-RNP (antiribonucleoprotein)
        Anti-Smith
        Anti-Sjogrens syndrome     

Rheumatoid Factor
Normal < 80 IU/ml
Increased in rheumatoid arthritis, SLE, endocarditis, tuberculosis, syphilis, sarcoidosis, cancer, viral infections, Sjogren’s syndrome, skin & renal allografts, diseases affecting lung, liver, or kidney

Cold Agglutins Test
Normal < 1:16 titer  at 4^o C
A titer is finding the substance after a series of dilutions. In the case of a 1:16 titer the substance is present after a dilution of 16 times.
IgM autoantibodies cause RBCs to agglutinate at 0-10^o C
Used to diagnose atypical viral pneumonia, certain hemolytic anemias

Chronic elevation - severe Raynaud’s phenomenon, B-cell CLL
Transient increases: atypical viral pneumonias, infectious mononucleosis, congenital syphilis, hepatic cirrhosis, trypanosimiasis

There are a lot of other immune function tests. An important point to remember is that most are very nonspecific and will be positive after any inflammatory response.

Therapeutic Drug Monitoring

• Random - drawn with no relationship to when drug administered

• Peak - drawn 1 hour after IV or IM dose, or 2 hours after p.o.

• Trough - drawn immediately before next dose

Differs from toxicology screening only in whether the drug was prescribed and taken in a therapeutic manner.

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