3.11 Leukopenia

Leukopenia refers to an abnormally low number of circulating white blood cells (WBC). Neutropenia refers to an abnormally low level of neutrophils. Neutrophils are the immune system’s first line of defense. Without enough white blood cells, including enough neutrophils, the client is vulnerable to developing infections and can rapidly become septic.

Leukopenia and neutropenia are caused by other conditions such as autoimmune disease, malignancy, chemotherapy, or immunosuppressive medications.^[1],[2]

Assessment

Physical Examination

Leukopenia does not have specific symptoms. Clinical manifestations are related to infections that develop as a result of leukopenia, such as the following^[3]:

• Fever and chills
• Malaise
• Sore throat
• Productive cough of purulent sputum
• Painful urination and/or malodorous urine
• Wounds with purulent drainage
• Tachycardia and tachypnea
• New onset confusion in older adults

Diagnostic Testing

Leukopenia is diagnosed by evaluating a CBC. In general, a WBC count less than 4,000 mm³ is considered leukopenia, although the range can vary slightly by gender and age. Health care providers may order additional tests to evaluate suspected infection, such as a urinalysis/urine culture for a urinary tract infection, or a chest X-ray for suspected pneumonia.

A common reference range for neutrophils is called the absolute neutrophil count (ANC), which is calculated based on the percentage of neutrophils in the white blood cell count. The risk of opportunistic infection increases as the ANC falls below 1500/μL, and the risk of serious infection increases as the ANC falls to the severely neutropenic range (< 500/µL).

It is important to treat suspected infection very quickly in clients who have leukopenia and/or neutropenia because infections can quickly become severe and life-threatening due to their decreased immune response.

Nursing Diagnoses

Nursing diagnoses for clients with leukopenia and/or neutropenia are as follows:

• Risk for Infection
• Fatigue Related to Disease Process
• Readiness for Enhanced Knowledge

Outcome Identification

Here are examples of expected outcomes for a client with an abnormally low white blood cell count:

• The client will remain free from infection.
• The client will verbalize three energy conservation strategies by the end of the teaching session.

Interventions

Medical Interventions

When deciding on treatment, health care providers consider the cause and severity of the leukopenia. Mild cases may not require treatment other than prevention techniques like strict handwashing and avoiding others who are ill.

Medical treatments for leukopenia may include the following^[4]:

• Antibiotics for Fever: Fever in a client with leukopenia is assumed to be caused by an infection and is treated with antibiotics, even if the source of infection cannot be determined.
• Granulocyte Colony-Stimulating Factor (G-CSF): This medication stimulates the bone marrow to produce more white blood cells and is typically prescribed for clients with low WBCs resulting from chemotherapy.
• Stopping or Changing Medications: Medications that cause reduced WBCs are stopped or changed, if possible, in cases of drug-induced leukopenia. Medications that can impact WBCs include the following classes:
  • Chemotherapy Drugs: Many chemotherapy drugs used in cancer treatment can suppress the bone marrow’s ability to produce white blood cells, leading to leukopenia.
  • Antibiotics: Certain antibiotics, such as trimethoprim-sulfamethoxazole, linezolid, and some cephalosporins, can cause leukopenia as a side effect.
  • Anticonvulsants: Medications like phenytoin and carbamazepine, which are used to treat epilepsy and seizures, can sometimes lead to a decrease in WBCs.
  • Antipsychotic Medications: Clozapine is an antipsychotic medication known for its potential to cause agranulocytosis, a severe reduction in WBCs.
  • Antithyroid Medications: Methimazole and propylthiouracil, used to treat hyperthyroidism, can cause leukopenia and other blood disorders.
  • Immunosuppressants: Drugs like mycophenolate and azathioprine, used to suppress the immune system in organ transplant recipients and for autoimmune conditions, can reduce WBC counts.
  • Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): Some NSAIDs, including ibuprofen and naproxen, have been associated with leukopenia in rare cases.
  • HIV Medications: Certain antiretroviral drugs used to treat HIV, like zidovudine, can lead to decreased WBC counts.
• Stem Cell Transplants: Stem cell transplants may be used to treat severe leukopenia caused by bone marrow problems, such as leukemia.

Nursing Interventions

Nurses play a significant role in helping clients prevent infection, as well as identifying infection early in a person at risk. They also provide health teaching to clients and their family members on how to prevent infection. Nursing Interventions Classification (NIC) provides a list of evidence-based nursing interventions categories as “Infection Protection.”^[5] See selected nursing interventions related to this category in the following box.

Evaluation

During the evaluation stage, nurses determine the effectiveness of nursing interventions for a specific client. The previously identified expected outcomes are reviewed to determine if they were met, partially met, or not met by the time frames indicated. If outcomes are not met or only partially met by the time frame indicated, the nursing care plan is revised. Evaluation should occur every time the nurse implements interventions with a client, reviews updated laboratory or diagnostic test results, or discusses the care plan with other members of the interprofessional team.