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Introduction ⬇

Neutrophils, the most numerous and important type of leukocytes in the body’s reaction to inflammation, constitute a primary defense against microbial invasion through the process of phagocytosis. These cells can also cause some body tissue damage by their release of enzymes and endogenous pyrogens. In their immature stage of development, neutrophils are referred to as “stab” or “band” cells. The term band stems from the appearance of the nucleus, which has not yet assumed the lobed shape of the mature cell.

This test determines the presence of neutrophilia or neutropenia. Neutrophilia is an increase in the absolute number of neutrophils in response to invading organisms and tumor cells. Neutropenia occurs when too few neutrophils are produced in the marrow, too many are stored in the blood vessel margin, or too many have been called to action and used up.

Normal Findings ⬆ ⬇

Absolute neutrophil count (ANC): 1500–7000/mm3 or 1.5–7 × 109/L

Black adults: 1.2–6.6 × 109/L

Differential: 50%–70% of total WBC count

0%–3% of total PMNs are stab or band cells

Procedure ⬆ ⬇

  1. Obtain a 5-mL blood sample in a lavender-topped tube (with EDTA); label the specimen with the patient’s name, date and time of collection, and test(s) ordered and place it in a biohazard bag.

  2. Count as part of the differential.

Clinical Implications ⬆ ⬇

  1. Neutrophilia (increased ANC and relative percentage of neutrophils) >8.0 × 109/L or 8000/mm3; for Black patients: >7.0 × 109/L or 7000/mm3

    1. Acute, localized, and general bacterial infections. Also, fungal and spirochetal and some parasitic and rickettsial infections

    2. Inflammation (e.g., vasculitis, rheumatoid arthritis [RA], pancreatitis, gout) and tissue necrosis (myocardial infarction [MI], burns, tumors)

    3. Metabolic intoxications (e.g., diabetes, uremia, hepatic necrosis)

    4. Chemicals and drugs causing tissue destruction (e.g., lead, mercury, digitalis, venoms)

    5. Acute hemorrhage, hemolytic anemia, hemolytic transfusion reaction

    6. Myeloproliferative disease (e.g., myeloid leukemia, polycythemia vera, myelofibrosis)

    7. Malignant neoplasms—carcinoma

    8. Some viral infections (noted in early stages) and some parasitic infections

  2. Ratio of segmented neutrophils to band neutrophils: normally, 1%–3% of PMNs are band forms (immature neutrophils).

    1. Degenerative shift to left: In some overwhelming infections, there is an increase in band (immature) forms with no leukocytosis (poor prognosis).

    2. Regenerative shift to left: There is an increase in band (immature) forms with leukocytosis (good prognosis) in bacterial infections.

    3. Shift to right: Decreased band (immature) cells with increased segmented neutrophils can occur in liver disease, megaloblastic anemia, hemolysis, drugs, cancer, and allergies.

    4. Hypersegmentation of neutrophils with no band (immature) cells is found in megaloblastic anemias (e.g., pernicious anemia) and chronic morphine addiction.

  3. Neutropenia (decreased neutrophils)

    1. <1500/mm3 or <1.5 × 109/L

    2. Black patients: <1000/mm3 or <40% of differential count

    3. Causes associated with decreased or ineffective production

      1. Inherited stem cell disorders and genetic disorders of cellular development

      2. Acute overwhelming bacterial infections (poor prognosis) and septicemia

      3. Viral infections (e.g., mononucleosis, hepatitis, influenza, measles)

      4. Some rickettsial and parasitical (protozoan) diseases (malaria)

      5. Drugs, chemicals, ionizing radiation, venoms

      6. Hematopoietic diseases (e.g., aplastic anemia, megaloblastic anemias, iron-deficiency anemia, aleukemic leukemia, myeloproliferative diseases)

    4. Causes associated with decreased survival

      1. Infections mainly in persons with little or no marrow reserves, older people, and infants

      2. Collagen vascular diseases with antineutrophil antibodies (e.g., systemic lupus erythematosus [SLE] and Felty syndrome)

      3. Autoimmune and isoimmune causes

      4. Drug hypersensitivity (There is an extensive list of drugs that continues to grow. Women are more likely than men to have a drug sensitivity. Removal of offending drug results in return to normal.)

      5. Splenic sequestration

    5. Neutropenia in neonates (<5000/mm3 or <5.0 × 109/L or <1000/mm3 or <1.0 × 109/L after first week of life)

      1. Maternal neutropenia, maternal drug ingestion, maternal isoimmunization to fetal leukocytes (maternal immunoglobulin G [IgG] antibodies to fetal neutrophils)

      2. Inborn errors of metabolism (e.g., maple syrup urine disease)

      3. Immune deficits—acquired

      4. Deficits and disorders of myeloid stem cell (e.g., Kostmann agranulocytosis, benign chronic granulocytopenia of childhood)

      5. Congenital neutropenia

    6. Pregnancy—progressive decrease until labor

  4. Other leukocyte abnormalities and corresponding diseases are listed in Table 2.3.

Interventions ⬆ ⬇

Pretest Patient Care

  1. Explain test purpose and procedure.

  2. Refer to standard pretest care for CBC and differential count. Also, follow guidelines in Chapter 1 for safe, effective, informed pretest care.

Posttest Patient Care

  1. Review test results; report and record findings. Modify the nursing care plan as needed. Counsel the patient regarding abnormal findings; explain the need for possible follow-up testing and treatment.

  2. Monitor for neutrophilia or neutropenia.

  3. Refer to standard posttest care for CBC and differential count. Also, follow guidelines in Chapter 1 for safe, effective, informed posttest care.

Clinical Alert

Agranulocytosis (marked neutropenia and leukopenia) is extremely dangerous and is often fatal because the body is unprotected against invading agents. Patients with agranulocytosis must be protected from infection by means of protective (reverse) isolation techniques with strictest emphasis on proper hand hygiene

Interfering Factors ⬆

  1. Physiologic conditions such as stress, excitement, fear, vomiting, electrical shock, anger, joy, and exercise temporarily cause increased neutrophils. Crying babies have neutrophilia.

  2. Obstetric labor and delivery cause neutrophilia. Menstruation causes neutrophilia.

  3. Steroid administration: Neutrophilia peaks in 4–6 hours and returns to normal by 24 hours (in severe infection, expected neutrophilia does not occur).

  4. Exposure to extreme heat or cold

  5. Age

    1. Children respond to infection with a greater degree of neutrophilic leukocytosis than adults do.

    2. Some older patients respond weakly or not at all, even when infection is severe.

  6. Resistance

    1. People of any age who are weak and debilitated may fail to respond with a significant neutrophilia.

    2. When an infection becomes overwhelming, the patient’s resistance is exhausted and, as death approaches, the number of neutrophils decreases greatly.

  7. Myelosuppressive chemotherapy

  8. Many drugs cause increases or decreases in neutrophils.