CONTINUING EDUCATION

Understanding the Complete Blood

Count With Differential
Beverly George-Gay, MSN, RN, CCRN
Katherine Parker, MEd, RN

The complete blood count (CBC) with differential is one of the most common
laboratory tests performed today. It gives information about the production of
all blood cells and identifies the patients oxygen-carrying capacity through the
evaluation of red blood cell (RBC) indices, hemoglobin, and hematocrit. It also
provides informa-tion about the immune system through the evaluation of the
white blood cell (WBC) count with differential. These tests are helpful in
diagnosing anemia, certain cancers, infection, acute hemorrhagic states,
allergies, and immunodeficiencies as well as monitoring for side effects of
certain drugs that cause blood dyscrasias. Nurses in the perianesthesia arena
are frequently challenged to obtain and evalu-ate all or parts of the CBC as a
part of the patients preoperative, intraoperative, and postoperative
assessments. An enhanced under-standing of this laboratory test is essential to
providing quality care. 2003 by American Society of PeriAnesthesia Nurses.

ObjectivesBased on the content of this article, the reader should be able to

(1) discuss the physiology of blood cell production; (2) describe the usefulness
of the complete blood count (CBC);
(3)identify and differentiate the roles of the different types of leukocytes; (4)
describe the charac-teristics of red blood cell (RBC) structure and function; (5)
discuss the indications for CBC as part of the perianesthesia evaluation; and (6)
explore the nursing indications related to CBC findings in the perianesthesia
setting.
2003 by American Society of PeriAnesthesia
Nurses. 1089-9472/03/1802-0007$35.00/0
doi:10.1053/jpan.2003.50013
Beverly George-Gay, MSN, RN, CCRN, is the
Nurse Educator for Critical Care for the
Department of Education and Katherine Parker,
MEd, RN, is a Nurse Educator for the Department
of Education at the Virginia Commonwealth
University Health System, Richmond, VA.

Address correspondence to Beverly George-Gay,

MSN, RN, CCRN, 11824 Club Ridge Dr, Chester, VA
23836; e-mail address: bgay@mcvh-vcu.edu.
 determinations of hemoglobin,
THE COMPONENTS OF the hemato-crit, and RBC indices (Table
complete blood count (CBC) include a 1). The WBC count with differential
hemogram and differen-tial white enumerates the different WBC types.
blood cell (WBC) count. The hemo- Together, the components of the CBC
gram includes the enumeration of evaluate primary diseases of the
WBCs, red blood cells (RBCs), and blood and bone
platelets; it also pro-vides
96 Journal of PeriAnesthesia Nursing, Vol 18, No 2 (April), 2003:
pp 96-117
UNDERSTANDING THE CBC WITH and applica-tions for the
DIFFERENTIAL perianesthesia nurse are
Table 1. Complete Blood Count
discussed.

WBC Screening
Differential white cell count
RBC Screening usually refers to
Hct testing patients who are
Women
Men 8 to 64 yr
asymptomatic and have no
Men 65 to 74 yr physical signs of disease. However,
Hgb symptoms or physi-cal signs may
Women
Men
be very insensitive indicators of
RBC indices some diseases. In the
Mean corpuscular volume perianesthesia setting, the use of
Mean corpuscular Hgb
Mean corpuscular Hgb concentration
the CBC as a screening tool
Platelet count constantly undergoes revision.
1 Factors such as the preva-lence of
Data from Chernecky et al.
disease in a population, the
medical and financial impact of
marrow, which include disorders such missing a problem, the cost per
as ane-mia, leukemia, polycythemia, problem found, financial
thrombocytosis, and reimburse-
thrombocytopenia. The CBC also
evaluates medical conditions that
secondarily affect the blood and bone
marrow resulting in hemato-logic
manifestations such as infection,
inflam-mation, coagulopathies,
neoplasms, and toxic substance
exposure. In many instances, specific
symptomatology of a medical
condition may not be present and
hematologic changes on the CBC may
be the only finding present. These
changes prompt investigation to then
identify the medical condition.

To foster the understanding of the

usefulness of the CBC, the function
and life cycle of the various cells are
introduced. Test indications,
characteristics, abnormal findings,
 97
ment, and societal judgments determine
when screening tests are indicated.
Medicare does not support the use of
the CBC as a screening tool; to be cost
effective, the CBC should only be
ordered when indicated.2
Indications
Preoperative evaluation should include a
his-tory, a physical examination,
laboratory tests, and an assessment of
surgical risk to identify coexisting
diseases and complicating condi-tions.
To decrease the risk of morbidity and
mortality in the perianesthesia setting,
the CBC is used to assist with the
identification of pa-tients who are at risk
for complications of inad-equate tissue
perfusion during the procedure and
those with a possible infectious or
inflam-matory process.3,4
General indications for a CBC that are
consid-ered medically reasonable and
are accepted by Medicare are as follows:
The hemogram should be
evaluated for any patient with
signs, symptoms, or conditions
associated with anemia or
polycythemia. See Table 2 for
specific signs, symptoms, and
conditions.
The platelet count should be
evaluated for patients with
findings or conditions associated
with increased or decreased
platelet production, destruction,
or dys-function (Table 2). The
platelet count is usually obtained
as part of the hemo-gram.
The WBC differential should be
evalu-ated for any patient with
signs, symp-toms, or conditions
associated with in-fections,
inflammatory processes, bone
marrow alterations, and immune
disor-ders (Table 2). The WBC
count has also been recently
identified as a possible risk
stratification tool for mortality in
acute coronary syndromes.5
A hemoglobin and hematocrit
(H&H) alone may be appropriate
if there is only a need to assess
the oxygen-carrying ca-
98

Table 2. Signs, Symptoms, and Conditions That May Warrant a CBC or Parts of a CBC

Hemogram
(Findings Related to Anemia)

Pallor
Weakness
Fatigue
Weight loss
Bleeding
Acute or suspected blood loss
from injury
Hematuria
Hematemesis
Hematochezia
Positive fecal occult
Neuropathy
Malnutrition
Tachycardia
Known malignancy
Systolic heart murmur
Congestive heart failure
Dyspnea
Angina
Postural dizziness
Syncope
Nailbed deformities
Known malignancy
Jaundice
Hepatomegaly
Splenomegaly
Lymphadenopathy
Ulcers of the lower extremities

Abbreviations: COPD, chronic obstructive pulmonary disease; DIC, disseminated intravascular coagulation; SLE, systemic lupus erythematosus; RA,
rheumatoid arthritis.
Data from Centers for Medicare and Medicaid Services (CMS). Available at www.cms.hhs.gov/ncd/searchdisplay.asp?NSD_ID 61&NCD_vrsn_num 1.
Specific perianesthesia indications
for the CBC also take into account
the level of surgical com-
pacity of blood before surgery for
pa-tients who do not have the
previously listed signs,
symptoms, or conditions (Table
2). The H&H may be helpful in
the intraoperative and
postoperative phase of care to
assess and track for blood loss
but can be misleading because of
the intercompartmental fluid
shifts that occur during surgery
and because of the dilutional
effects of crystalloid ther-apy.
 mind that a minor procedure may
turn into a moderately complex
procedure as complica-tions are
plexity for a given procedure. In
identified or develop. Major proce-
general, minor procedures are those
dures are those that are often
with very low risk of large fluid shifts
prolonged, often with high risk of
or significant blood loss. Minor pro-
large fluid shifts or signifi-cant blood
cedures include soft tissue and eye
loss. They often involve major body
procedures; minor ortho; as well as
cavities. These include major
ear, nose, and throat and urologic
abdominal, vascu-
procedures, among others. Keep in
UNDERSTANDING THE CBC WITH DIFFERENTIAL

Table 3. Levels of Surgical Complexity

Level 1
Minimal risk to the patient independent of anesthesia
Minimally invasive procedures with little or no blood loss
Often performed in an office setting with the operating room principally for anesthesia and monitoring
Includes breast biopsy, removal of minor skin or subcutaneous lesions, myringotomy tubes, hysteroscopy, cystoscopy, fiberoptic
bronchoscopy
Level 2
Minimal to moderately invasive procedure
Blood loss less than 500 mL
Mild risk to patient independent of anesthesia
Includes diagnostic laparoscopy, dilatation and curettage, fallopian tubal ligation, arthroscopy, inguinal hernia repair, laparoscopic lysis of adhesions,
tonsillectomy/adenoidectomy, umbilical hernia repair, septoplasty/rhinoplasty, percutaneous lung biopsy, extensive superficial procedures
Level 3
Moderate to significantly invasive procedure
Blood loss potential 500 to 1,500 mL
Moderate risk to patient independent of anesthesia
Includes hysterectomy, myomectomy, cholecystectomy, laminectomy, hip/knee replacement, major laparoscopic procedures,
resection/reconstructive surgery of the digestive tract; excludes open thoracic or intracranial procedures Level 4

Highly invasive procedure

Blood loss greater than 1,500 mL
Major risk to patient independent of anesthesia
Includes major orthopedic-spinal reconstruction, major reconstruction of the gastrointestinal tract, major vascular repair without postoperative ICU stay

Level 5
Highly invasive procedure
Blood loss greater than 1,500 mL
Critical risk to patient independent of anesthesia
Usual postoperative ICU stay with invasive monitoring
Includes cardiothoracic procedure; intracranial procedure; major procedure on the oropharynx; major vascular, skeletal, neurologic repair
indicated at all. For those patients
undergoing major proce-dures, a CBC
lar, cardiothoracic, orthopedic, with platelets should be com-pleted.
gynecologic/ urologic, head and neck, The CBC is indicated for elderly
and neurologic proce-dures. Levels of patients
surgical complexity from level 1
(minor) to level 5 (major) are
described in Table
3. The American Society of
Anesthesiologists (ASA) physical
status classification system is an-
other tool that can be used to assess
the pa-tients current health status
and overall periop-erative risk (Table
4). Although imprecise, it is a way to
predict the patients
anesthetic/surgical risks. The higher
the ASA class, the greater the risks.

For the patient who is asymptomatic

and active with a reliable benign
history and undergoing a minor
procedure, an H&H assessment may
be all that is necessary or may not be
 Optimally efficient testing entails
( 65 years of age) as part of their consideration of a combination of
preoperative assessment because of factors including the age, gender, and
the comorbidities associ-ated with reliability of the patient; the surgi-cal
this age group as it may uncover procedure; and the type of anesthesia
clinical problems that were not being used. Older or less reliable
picked up on physical examination. 6 patients may be more likely to have
Patients classified with an ASA score an unsuspected abnormality picked
of 3 or greater should have a CBC up by a screening test. Major
before their surgical procedure. In proce-dures are associated with
addition to the general indications for significant physiologic stress.
CBC in Table 2, situations requiring a Existing medical conditions, which
CBC before a surgical procedure are may
listed in Table 5.
100 GEORGE-GAY AND
PARKER
Table 4. ASA Classification

Class Description Examples

1 A normal healthy patient with no systemic illness
2 A patient with well-controlled systemic illness, but
without functional restrictions
3 A patient with significant degree of systemic effects that
limits activities
4 A patient with severe systemic illness associated with
significant dysfunction and a constant potential threat to
life
5 A patient in critical condition, who is at substantial risk
of death within 24 hours with or without operative
procedure
6 A patient declared brain dead undergoing organ removal
for donor purposes
E This symbol is added to any of the above classes to
designate an emergency
Healthy with good exercise tolerance
Well-controlled hypertension, diabetes, without systemic effects; no
evidence of COPD, anemia, or obesity
Controlled heart failure, stable angina, or history of myocardial
infarction; diabetes with systemic sequela; uncontrolled
hypertension; morbid obesity
Unstable angina, symptomatic heart failure, renal failure requiring
dialysis
Multiple organ dysfunctions, hemodynamically unstable sepsis,
poorly controlled coagulopathy

Data from www.asahq.org, www.nurse-anesthesia.com/generalanesthesia.htm, and www.vh.org/adult/provider/anesthesia/proceduralsedation/

asapatientclassification.html. Accessed December 2002.
or treatment. Repeat testing is
indicated for abnor-mal results or for
be of little concern during a brief and patients with normal results who
minor procedure, may cause have conditions in which there is a
problems during and af-ter a long and con-
complex surgery. Preoperative
evaluation should reflect this need for Table 5. Situations Requiring Preoperative CBC
an in-creased level of preparedness Evaluation

and monitoring. Abnormal bleeding ( platelets)

Heavy ETOH use ( platelets)
Potentially toxic medications (eg, which cause bone marrow
Timing of the CBC depression)
Infection ( differential)
A CBC completed within 2 months of ASA score of $3
a proce-dure is acceptable unless a Vascular surgery
change is suspected as a Anticipate prosthetic device or hardware placement
Anticipate 500 mL blood loss, invasive monitoring, or ICU
consequence of disease, medication, ( platelets)
 Level 4 or 5 surgery

Abbreviation: ETOH, alcohol. tinued risk for the development of

hematologic abnormalities.

Blood
The average adult has approximately
5.5 L of blood, consisting of plasma
and cells. Plasma makes up 55% of
the blood components and consists of
proteins, water, and some waste
products. Cells, of which there are 3
main types, make up the other 45%.
They consist of
(1) WBCs (leukocytes), of which there
are sev-eral subtypes; (2) RBCs
(erythrocytes); and (3) platelets
(thrombocytes).

All blood cells are produced in the

bone mar-row from a mother cell
called the pluripotential
(multipotential) stem cell (PSC). This
PSC un-dergoes stages of
differentiation until it be-comes
committed to either the erythrocyte,
thrombocyte, or one of the leukocyte
subtypes (Fig 1). Under normal
conditions, only mature blood cells
should be found circulating in the
blood. Alterations in the production
and func-tion of these blood cells
provide information about the
patients diagnosis, prognosis, re-
UNDERSTANDING THE CBC WITH DIFFERENTIAL

16
Fig 1. Blood cell differentiation. Reprinted with permission from Garrett.
ation of the blood cells. Blood cell
counts are reported per microliter.
sponse to therapies, and their
recovery. The laboratory procedure Morphology is deter-mined by stained
that gives us this informa-tion is the smears.
CBC.

Obtaining the Blood Sample

The blood sample is obtained via
venipuncture and is collected in a
lavender top tube, which is the
nationally accepted color standard.
The blood sample will remain useable
for analysis at room temperature for
up to 10 hours, after which time the
sample deteriorates and is not to be
considered reliable. The blood sample
can also be kept refrigerated and
remain useable for as long as 18
hours. The sample should never be
frozen. The patient should ideally be
at rest for 10 to 15 minutes before
obtaining the sample. Automated
electronic devices perform enumer-
 inflammation/infec-tion and immunity
The WBC Count With is provided.
Differential Inflammation and Infection
The WBC count with differential The inflammatory process is
determines the total number of WBCs triggered by cell injury, which can be
(also called leuko-cytes) with a caused by a variety of conditions such
percentage of each type. The major as trauma, burns, ischemia, sur-gery,
function of the WBC is to defend the snakebite, caustic chemicals, and ex-
body against organisms and injury. tremes in heat and cold, as well as
WBCs are the main players in infectious microorganisms. It is
infectious/inflammatory and immune important to remember that although
responses. To appreciate the role of all infections are accompanied by
the WBC, a brief review of inflammation, not all inflammation is
accompa-
102
increases blood flow to the area,
bringing nutrients and large amounts
nied by infection. In the
of WBCs. Vasodilation also re-sults in
perianesthesia setting, surgical
hyperemia (redness and warmth). An-
incisions would be the most common
other manifestation is increased
trigger of inflammation.
capillary per-meability, which allows
Any damage to the vascular for the immigration of WBCs from the
endothelium or the mast cell will blood vessel to the interstitial spaces
trigger an inflammatory response, where they can phagocytize
which is orchestrated by unwanted organisms and debris. The
inflammatory cyto-kines. Cytokines WBCs also release cytokines to call
are hormonelike protein medi-ators more WBCs to the area and to
responsible for the cell-to-cell perpetuate the inflammatory
commu-nication that regulates local response. In-creased capillary
and systemic physiologic and permeability also allows for the
pathologic interactions. The cells of exudation of plasma and plasma
the vascular endothelium have been proteins resulting in edema. The
recently identified as a major player edema may cause pres-sure on the
in the inflammatory process. nearby nerves resulting in pain.
Immunity
The mast cell (cellular bag of In the immune process, specific types
granules) is an-other important of WBCs respond to specific
activator of the inflammatory microorganisms. Immunity can be
response. Mast cells are found in classified as either cell mediated or
connective tissues intimately hu-moral. Cell-mediated immunity
surrounding blood vessels and in involves spe-cific types of WBCs
mucosal surfaces. Once endothelial or called T lymphocytes or T cells. These
mast cells are injured or damaged, T cells will attack host cells within
they release in-flammatory cytokines,
which orchestrate the manifestations
of inflammation.

Manifestations of inflammation
include a short period of
vasoconstriction to limit bleeding fol-
lowed by vasodilation. Vasodilation
 GEORGE-GAY AND
PARKER
tissue that have been infected by
microorgan-isms, as well as cancer
cells. Cell-mediated im-munity
provides primary defense against vi-
ruses, fungi, slow-growing bacteria,
and tumors.
Humoral immunity or antibody-
mediated im-munity involves the
production of antibodies by B cells
and mainly occurs in body fluid such
as plasma and lymph. Humoral
immunity pro-vides primary defense
against bacteria. Cell-me-diated
immunity is initiated frequently first,
but both cell-mediated and humoral
immunity can be initiated
simultaneously. Both types of immu-
nity require specific types of WBCs to
be effec-tive.
White Blood Cells
Although the medical term for the
WBC is leu-kocyte, the term WBC will
be used in this article for the sake of
simplicity. WBCs can be divided into 2
main groups: phagocytes and
immuno-cytes. Phagocytes are WBCs
that have the capa-bility to attach to,
engulf, and release enzymes to kill
and degrade unwanted
microorganisms and debris. The
WBCs that are phagocytic in-clude
neutrophils, eosinophils, basophils,
and monocytes. Immunocytes include
the lympho-cytes, WBCs that drive
the immune response.
A more common manner in which
WBCs are divided is by the presence
of granules in the cytoplasm. Those
WBCs that contain granules in their
cytoplasm are neutrophils,
eosinophils, and basophils. WBCs
that do not contain gran-ules in their
cytoplasm include monocytes and
lymphocytes (Fig 2). For the purpose
of this discussion, WBCs will be
divided into granulo-cytes and
nongranulocytes.
Granulocytes
Granulocytes get their name from the
granules present in their cytoplasm.
These granules con-tain biochemical
mediators that serve inflamma-tory
and immune functions. Granulocytes
also contain enzymes in their
cytoplasm capable of destroying
microorganisms and catabolizing de-
bris ingested during phagocytosis.
They take about one week to develop
in the bone mar-
UNDERSTANDING THE CBC WITH DIFFERENTIAL

8
Fig 2. Granulocytes and nongranulocytes. Reprinted with permission from Catalano.
When there is an increased demand
row. They circulate for only about 6 to for neutro-phils, as in response to
12 hours in the blood stream and 2 to acute infection, imma-ture
3 days after enter-ing the tissue. neutrophils may be released from the
bone marrow. These immature cells
Neutrophils have unseg-
Neutrophils are a type of granulocyte
and are mature cells that account for
more than half of all the WBC
subtypes in circulation. They are also
called segmented neutrophils (segs)
or polymorphonuclear neutrophils
(PMNs) or polys because the nucleus
of these cells consists of 3 to 5 lobes
connected by thin strands. Highly
motile, these cells are the first to
arrive (usually within 90 minutes) in
response to acute inflammation or
infection; they migrate out of the
capillaries and into the inflamed
tissue site in a process called
diapedesis or emigration. The
neutrophils ingest microorganisms
and de-bris and then die, forming
purulent exudate, which is removed
by the lymphatics or through the
epithelium.

mented nuclei that resemble bands or
rods. Thus, immature neutrophils are
called bands or stabs. They are
normally found only in very low
percentages in circulating blood.
Eosinophils
Eosinophils function principally to
ingest and kill multicellular parasites.
They are also effec-tive in detoxifying
antigen-antibody complexes that form
during allergic reactions. People with
chronic allergic conditions such as
atopic rhini-tis and extrinsic asthma
typically have elevated circulating
eosinophil counts. Eosinophils are
104
mast cells are found in connective
tissue. The average basophil has a life
span of days, but the mast cell can
live weeks to months.
Nongranulocytes
Nongranulocytes, as mentioned
earlier, are WBCs that do not have
granules in their cyto-plasm.
Inclusive in this group are monocytes
and lymphocytes.
Monocyte/Macrophage
Monocytes are the largest of the
WBCs and are young cells found
freely circulating in blood or en route
to a tissue location. Once the young
monocyte leaves the blood stream
and enters tissue, it transforms into a
mature macrophage. Macrophages
live within tissue spaces in wide-
spread locations. These cells have
different names related to the
particular tissue in which they are
found, ie, the Kupffer cells are macro-
phages that live in the liver. Because
of the complex connection of these
cells to the blood stream and the
tissue, monocytes and macro-phages
are described as one system, called
the mononuclear phagocyte system.
Table 6 iden-tifies specific
believed to play a role in
downregulating hyper-sensitivity
responses by neutralizing histamine,
inhibiting mast cell degranulation, and
inactivating slow-reacting subtances
(SRS) of anaphylaxsis.
Basophils
Basophils are associated with
systemic allergic reactions. Similar to
mast cells, basophils have granules
that contain proinflammatory chemi-
cals such as histamine, serotonin,
bradykinin, and heparin. They release
their granules in re-sponse to
stimulation by immune cells. Ba-
sophils circulate in the blood stream,
whereas
macrophages and the particular
tissue in which they are found.
Macrophages arrive on the scene in
about 5 hours after injury and
become the predominant leukocyte
within 48 hours. Because macro-
phages lie within the tissue spaces,
they are usually the first cell to
engulf and process the antigen and
present it to the immune cells
(lymphocytes) in a manner that will
stimulate a specific immune response
to that particular an-tigen. In other
words, the macrophage, in a special
process, can destroy the organism
while keeping its cell surface markers
to give to the lymphocytes so that
they can always identify that
particular organism and mount a
specific defense against it.
Lymphocytes
Lymphocytes are also
nongranulocytes and are responsible
for immune responses to specific
organisms. They are the most
numerous circu-lating WBC after
neutrophils. There are 2 major
 GEORGE-GAY AND PARKER
Table 6. Mononuclear Phagocyte System
Macrophage
Kupffer cells
Alveolar macrophage
Histocytes
Pleural and peritoneal macrophages
Microglial cells
Osteoclasts
Mesangial
Langerhans
Dendritic cells
classes of lymphocyte: the T
lymphocyte (T cell) and the B
lymphocyte (B cell). Both T and B
cells can be sorted into subtypes
based on characteristic surface
molecules on them called cluster of
differentiation (CD). Cluster of differ-
entiation surface molecules assist in
defining the function of the different
lymphocyte sub-types.
T cells. The T cell matures in the
thymus and is responsible for cell-
mediated immunity as previously
described. The T cell can also stim-
ulate the B cell, triggering
UNDERSTANDING THE CBC WITH
DIFFERENTIAL
cells and cancer cells and releases
enzymes to destroy these cells.
Cytotoxic T cells are par-ticularly
effective at destroying virally in-
fected cells, foreign cells, and mutant
cells.7 Memory T cells are produced
after invasion by a specific organism.
They provide long-lasting immunity
against that particular organ-ism and
then wait to rapidly respond to a
second attack by the same organism.
Their average survival rate is about 5
years.
B cells. The B cell matures in the
bone mar-row and is responsible for
humoral, also known as antibody-
mediated, immunity. When an anti-
humoral/anti-body-mediated
immunity (also previously de-
scribed). The T cell has several
subtypes that can be divided into
regulator or effector cells.
Regulator T cells are so called
because of their regulatory functions
of turning on or off the immune
response. There are 2 types of regula-
tor T cells: the helper T cell and the
suppressor T cell. The helper T cell is
considered the master switch of the
immune system. These cells are
surveyors, and when a specific
antigen is presented to them, they
release mediators that influence and
stimulate the production of other
immune cells including B cells.
Helper T cells have CD4 surface
molecules on them. Suppressor T
cells suppress the immune re-sponse
once the infection is controlled.
Effector cells are T cells that have a
direct action. The 2 types of effector
cells are the cytotoxic T cell and the
memory T cell. The cytotoxic T cell
carries the CD8 molecule on its
surface. It attaches to identified
infected
gen (foreign body) is presented to
the B cell, either by a macrophage
or helper T cell, the B cell
becomes activated to produce
plasma cells. The plasma cell then
releases antibodies spe-cific for
that specific antigen.
Natural killer cells. There is a
third class of lymphocyte that does
not have T- or B-cell markers
called natural killer (NK) cells. NK
cells are nonspecific and can
therefore re-spond to a variety of
antigens. They are very effective
against tumor cells and virally in-
fected host cells.
Evaluating the WBC
Count With Differential
The white count differential is
expressed in cubic millimeters and in Table 7. Normal White Blood Cell Counts
percentages. See Table 7 for normal Cell Type
values of the differential.
Total WBC
Elevated Counts/Levels Granulocytes
Neutrophils
An elevation in the total WBC count Segmented
(WBC 11,000/mL) is called Bands
leukocytosis. Leukocyto-sis most Eosinophils
Basophils
commonly identifies infection, tissue Nongranulocytes
inflammation, or tissue necrosis Monocytes
associated with disorders such as Lymphocytes (Immunocytes)
acute myocardial infarction, burns, T cells
B cells
gangrene, leukemia, radiation Natural killer
exposure, extremes in heat or cold, or
lymphoma.8 A WBC count of greater *Percent of total lymphocyte count.

than 10,000 has been associated with

increased mortality rates in pa-tients
with acute coronary syndromes and is
now being used by some as a
predictor of adverse outcomes in
these patients.5,9 The role of
inflammation in the pathogenesis of
ischemic
stroke is also currently being studied.
Patients with elevated WBC counts
during the stroke event have been
found to have a greater relative risk
of subsequent ischemic stroke than
did those with lower WBC counts. 10
Thus, an ele-vated WBC count is
being looked at as a predic-tor of
ischemic stroke. Severely elevated
total WBC counts ( 100,000), as seen
in leukemia, promotes circulatory
sludging and increased blood
viscosity. Venous thromboembolism
(VTE) prophylaxis is required in these
situa-tions.11

Leukocytosis may also occur in

response to physical and emotional
stressors such as over-exertion,
seizures, anxiety, anesthesia, and epi-
nephrine administration. With stress
leukocyto-sis, however, the WBC will
return to normal within an hour.
Certain medications such as
corticosteroids, lithium, and b-
agonists may also cause leukocytosis.

In the preoperative setting, an

elevation in the WBC count
frequently causes postponement or
cancellation of a surgical procedure
for further evaluation. If the total
WBC count is elevated, the
differential and the patient should be
evalu-ated and the surgeon and to discriminate among stress
anesthesia provider notified. The leukocytosis, drug administration,
patients medication record and recent recent ischemia, myocardial in-
history should also be closely reviewed
106
severely elevated neutro-phil count
will be seen in certain pathologic
farction, or infection as possible
conditions causing the neutrophils to
causes. An evaluation of the
become hypermature. Hypermature
differential will allow for fur-ther
segmented neutro-phils are those in
discrimination.
which nuclear segmentation is
Neutrophilia impaired, and there is an increased
Neutrophilia is an increase in the number of segments ( 5). This is seen
total neutro-phil count (including in liver disease, Downs syndrome,
both segs and bands). Because and megaloblastic and per-nicious
neutrophils account for greater than anemia.
96% of all granulocytes, neutrophilia
may also be referred to as An elevation in bands is referred to
granulocytosis. It is the most common as a shift to the left, which means
cause of elevated WBC count. that there is an increased number of
immature neutrophils released from
Neutrophilia is most commonly
caused by an acute bacterial
infection. Neutrophil counts will rise
4 to 6 hours after an invasion by
microor-ganisms. If findings do not
suggest infection, a
myeloproliferative disorder may be
the cause. Myeloproliferative
disorders include polycythe-mia vera
and chronic myelocytic leukemia,
which increases stem cell
proliferation in the bone marrow.
Elevations in neutrophil counts are
also associated with obesity and
cigarette smoking. Additionally,
neutrophil counts can increase after
the stress of surgery, but in this case,
counts will quickly return to normal if
no infection is present.12

An elevation in segmented
neutrophils is con-sidered a shift to
the right. During tissue breakdown
from injuries such as burns, arthri-tis,
myocardial infarction, hemorrhage, or
elec-tric shock, neutrophils are called
in to clean up the damaged or dead
cells. In this case, reserve mature
neutrophils are called in, thereby in-
creasing the neutrophil count without
calling in the immature cells. A
 GEORGE-GAY AND
PARKER
the bone marrow and circulating in
the blood. This occurs in response to
overwhelming infec-tion when the
numbers of mature neutrophil
reserves have been depleted.
Clinically, the term shift to the left
specifies an acute bacterial infection
has depleted the normal reserves of
mature neutrophils, and the bone
marrow has had to resort to releasing
immature ones.
Generally, a shift to the right can be
considered a result of tissue damage
or necrosis, whereas a shift to the left
can be considered a result of an
overwhelming infection. As
mentioned earlier, however, an
increased neutrophil count is the
most common cause of an elevated
WBC count. Although not common,
the other types of WBCs can also give
rise to an elevation in WBC count.
Eosinophilia
Eosinophilia identifies an increase in
the eosin-ophil count. This count has
been found to increase with parasitic
infections such as toxo-plasmosis and
UNDERSTANDING THE CBC WITH
DIFFERENTIAL
Lymphocytosis
Lymphocytosis occurs in acute viral
infections such as mononucleosis,
cytomegalovirus, mea-sles, mumps,
and rubella. Elevated lymphocyte
counts will also be noted in patients
during chronic infections and early in
human immuno-deficiency virus (HIV)
disease. Severely elevated levels
would be seen with chronic
13
lymphocytic leukemia (CLL).
Decreased Counts/Levels
A decrease in the total WBC count
( 4,500/ mL) is called leukopenia.
Leukopenia re-sults from decreased
with infections by gastrointesti-nal
parasites. Elevations have also been
noted with bronchoallergic reactions
such as asthma, allergic rhinitis, and
hay fever. Eosinophilia has also been
noted with skin rashes.
Basophilia
Basophila is the most uncommon
cause of an elevated WBC count.
Increased basophil counts have been
found in patients with hypersensitiv-
ities compared with the general
population. These patients should
have a thorough allergy history
obtained before any surgical
procedure.
Monocytosis
Monocytosis, or increased monocyte
counts, occur late during the acute
phase of infection and with chronic
infections such as tuberculo-sis and
subacute bacterial endocarditis
(SBE). The patient with an elevated
monocyte count should be evaluated
for further evidence of these possible
conditions before surgical proce-
dures. Monocytosis also occurs with
Hodgkins disease, multiple myeloma,
some leukemias, and systemic lupus
erythematosus.
production of total WBCs in the
bone marrow or increased
destruction of WBCs. Total counts
will usu-ally fall with radiation
therapy and chemo-therapy as the
bone marrow is depressed. WBC
counts fall to the lowest points 7 to
14 days after induction of most
chemothera-peutic agents and will
then begin to in-crease as the bone
marrow normalizes. Pa-tients
receiving chemotherapy should
have their WBC counts closely
monitored. If leu-kopenia is
present, the patient should be
closely evaluated and the surgeon
and anes-thesia provider notified.
Blood cultures, si-nus and chest x-
rays, and urine and stool cultures
may also be necessary. As with an 107

elevated WBC count, an evaluation of

the differential will allow for further with increased splenetic pooling and
discrimina-tion. destruc-tion as seen in hypersplenism
or splenomegaly. Additionally, a
variety of drugs can cause neu-
tropenia such as certain
antimicrobials, non-steroidal anti-
Neutropenia inflammatory drugs, and some
Neutropenia is clinically defined as a analgesics. Other drugs include
neutrophil count of less than certain tricyclic antidepressants,
2,000/mL. Again, keep in mind that anticonvulsants, antithyroids,
the majority of all granulocytes (neu- cimetidine, and antidysrhythmic
trophils, eosinophils, and basophils) agents. Pa-tients with counts of less
are neutro-phils, which account for than 2,000/mL may be unable to
greater than 96% of all granulocytes. mount an adequate defense when
Because of this, the terms granu- challenged by infection. These
locytopenia (decreased granulocyte patients should be protected from
count) and neutropenia (decreased cross contamination and should not
neutrophil count) are used undergo surgical procedures when at
interchangeably in the clinical all possible.
setting. Neutropenia can occur with
severe prolonged infections that
exhaust the bone marrow sup-plies, Severe neutropenia is defined as a
where the production cannot keep up neutrophil count of less than 500/mL.
with the demand. It can also be This is also referred to as
because of increased destruction of agranulocytosis because a count this
WBCs that can occur low is almost equivalent to not having
any granulo-cytes at all. Neutrophil
counts below 500/mL predispose the
patient to serious bacterial infec-tion
and opportunistic infections of the
skin, mouth, pharynx, and lungs. As
counts fall be-low 100, the chance of
gram-negative and gram-positive
sepsis and fungal infections increases
dramatically.
Other Reductions
Reductions in eosinophil
(eosinopenia) and ba-sophil
(basopenia) counts are uncommon
be-cause so few of these cells
normally circulate in the blood.
Monocytopenia is a rare occurrence
but has been seen with glucocorticoid
therapy, hairy-cell leukemia, and
aplastic anemia. Lym-phopenia, a
decreased lymphocyte count, oc-curs
normally as a person ages.
Lymphopenia is most significant with
HIV and acquired immu-nodeficiency
syndrome (AIDS). A CD4 count The perianesthesia nurse should keep
(remember the helper T lymphocyte has in mind that the WBC count is a part
the CD4 marker on its surface) of less of a larger picture. One must look at
than 200 is one indicator of conversion the whole patient and put all
from HIV to AIDS. information into proper
14
perspective. Trends can help to
Nursing Implications identify truly abnormal findings.
108
Avoiding children who have just
been vaccinated
The surgeon and anesthesia provider Avoiding indiscriminate use of
should be notified for elevations in antipyret-ics
WBC count of greater than 11,000, or
decreases less than 4,500. Rec-ognize Avoiding steroid use, because
that minor alterations may be a they im-pede mediator functions
reflec-tion of age. One must blocking in-flammation; thus, the
determine whether the patient has patient will not show the true
enough neutrophils to combat and signs of inflammation or infection
protect from infection when counts
are low. Reporting a temperature greater
than 38C (100F), chills, sore
Leukocytosis commonly signals throat, dia-phoresis, or dysuria
infection, whereas leukopenia
Be suspect of the potential for
indicates bone marrow de-pression
septicemia in patients with a
that may result from viral infections neutrophil count of less than 500/mL.
or toxic reactions. Be alert to signs Moving forward with any surgical
and symptoms of infection, especially pro-
in patients with invasive lines,
indwelling urinary catheters, surgical
drains, and incision sites. General
signs of infec-tion include fatigue,
fever, a change in level of
consciousness (LOC), dehydration,
pharyngitis, or hypotension. More
frequent temperature monitoring may
be indicated.

Neutropenic precautions should be

considered for severely
immunocompromised patients and
those with severe neutropenia.
Neutropenic precautions include the
following:

Meticulous care of all intravenous

lines and indwelling catheters
Avoiding raw and uncooked
foods, in-cluding fresh fruits and
vegetables be-cause of
microorganism contamination
from soil

Avoiding crowds
 GEORGE-GAY AND (an enzyme) is secreted in response
PARKER to peritubular cell hy-poxia. This
factor interacts with a plasma pro-
cedure in patients with counts of less
tein to form erythropoietin, a
than 2,000/mL should be considered
hormone that circulates to the bone
only for emer-gent situations. Also
marrow to stimulate stem cells to
note that patients with WBC counts
produce more RBCs. RBCs are
greater than 100,000 are at an
released from the bone marrow as
increased risk for thrombosis because
reticulocytes and then become
of in-creased blood viscosity. Ensure
mature RBCs in one day.
adequate fluid intake and VTE
prophylaxis. See Table 8 for Vitamin B12, folic acid, and iron are
recommendations regarding VTE also needed for RBC metabolism.
prophylaxis in the surgical patient. Vitamin B12 and folic acid
Patients with recent ische-mic stroke
or myocardial infarction, and a con-
comitant elevation in WBC count may
be at increased risk for mortality or
morbidity.
Erythrocyte (RBC) Studies
The main function of the RBC is to
carry oxygen (O2), which it picks up
in the lungs, to the cells of the body,
and to transport carbon dioxide from
the cell to the lungs for excretion.
Essen-tially, RBCs are containers for
hemoglobin (Hgb). Hgb is the oxygen-
carrying protein of the RBC, which
accounts for approximately 90% of
the cells dry weight. Information
about the RBC is obtained with a CBC
but can also be obtained separately
with a hemogram.

RBCs are produced at a rate of 2

million cells per second, or 35 trillion
cells per day. The average life span is
approximately 120 days. The mature
RBC is a biconcave disk. This unique
shape allows for a greater surface
area for oxy-gen to combine with
Hgb. RBCs have no nu-cleus, and
therefore cannot divide. Like the
WBC, the RBC is derived from the
PSC in the bone marrow (Fig 1). The
production of RBCs by the bone
marrow is stimulated by low oxy-gen
levels in peritubular cells of the
kidney in a process called
erythropoiesis. During erythro-
poiesis, renal erythropoietic factor
UNDERSTANDING THE CBC WITH DIFFERENTIAL

Table 8. Venous Thromboemolism Prophylaxis

Type of Surgical Procedure

General surgery
Minor procedure without additional risk factors in Low risk
patients less than 40 years of age Early ambulation
Minor procedure with additional risk factors in Moderate risk
patients less than 40 years of age LDUH every 12 hours starting 1 to 2 hours before surgery
Minor procedure in patients 40 to 60 years of age LMWH first dose generally before surgery
without additional risk factors ES or IPC device to start immediately before procedure and continue until fully
Major surgery in patients without additional risk ambulatory
factors 40 years of age
Nonmajor surgery with additional risk factors in High risk
patients 60 yr LDUH every 8 hours, LMWH, or IPC device
Major surgery in patients 40 yrs or with
additional risk factors
Very high risk
Major surgery in patients 40 with multiple risk LDUH, LMWH, combined with mechanical method (ES or IPC device)
factors
LDUH twice a day, alternatively, LMWH or IPC device started just before surgery and
Gynecologic surgery continued at least several days postoperatively
Major surgery for benign disease without LDUH three times a day
additional risk factors For additional protection use LDUH plus ES or IPC device
Extensive surgery for malignancy
Prompt mobilization
Urologic surgery LDUH, ES, IPC device, or LMWH
Transurethral surgery or other low-risk procedure LDUH or LMWH and ES with IPC device
Major open urologic procedure
Highest risk patients LMWH started 12 hours before surgery, may be started 12 hours postoperatively; ES or
Orthopedic surgery IPC device should be added
Elective total hip replacement LDUH, aspirin, dextran, and IPC alone are not recommended
LMWH or adjusted dose warfarin to maintain an INR of 2 to 3
IPC is effective if used optimally; LDUH not recommended
Elective knee replacement LMWH or adjusted dose warfarin

Hip fracture surgery IPC with or without ES

Neurosurgery, trauma, & acute spinal cord injury LDUH or LMWH postoperatively are alternatives with a concern about
Intracranial neurosurgery intracranial hemorrhage
For high-risk patients the combination of mechanical and pharmacologic
prophylaxis may be more effective
LMWH started as soon as possible if no contraindications (risk of bleeding); if
contraindicated start ES and/or IPC
Trauma IVC filter is recommended if proximal DVT is seen and anticoagulation is
contraindicated; IVC filter is not recommended for primary prophylaxis
LMWH started as soon as possible; LDUH, ES, and IPC not recommended when used
alone. ES and IPC may benefit when used in combination with LMWH or LDUH, or if
Acute SCI anticoagulants are contraindicated.

For most patients, prophylaxis with LDUH or therapeutic doses of IV heparin are
Medical conditions recommended.
Acute myocardial infarction LDUH, LMWH or the heparinoid, danaparoid; if anticoagulation is
contraindicated, use ES or IPC device
Ischemic stroke LDUH or LMWH

General medical conditions with risk factors

NOTE. Risk factors include previous VTE, increasing age, major surgery, cancer, obesity, major trauma, lower extremity or hip fracture, pregnancy, history of
myocardial infarction, stroke, heart failure, hormone replacement therapy, prolonged immobilization, burns, paralysis, hypercoagulable states, indwelling
femoral vein catheter, inflammatory bowel disease.
Abbreviations: LDUH, low-dose unfractioned heparin; LMWH, low molecular weight heparin; ES, elastic stocking; IPC, intermittent pneumatic
compression; IFC, inferior vena cava; DVT, deep vein thrombosis; SCI, spinal cord injury.
Data from Geerts WH, Heit JA, Clagett GP, et al: Prevention of venous thromboembolism, Sixth ACCP Consensus Conference on Antithrombotic Therapy.
Chest 119:132s-175s, 2001, and Hirsh J: Managing venous thromboembolism: Methodology for achieving positive outcomes. CME-Today (Cardiopulmonary
and Critical Care) 1:11-15, 2002.
110
are needed for cell growth, DNA
synthesis, and for reproduction. Iron Table 9. RBC Count
is needed for Hgb syn-thesis.

Several tests are done to determine

Adult male
the ade-quacy of the RBC structure Adult female
and function, the RBC count, Hgb
concentration, hematocrit (Hct), and
RBC indices.

Erythrocyte (RBC) Count

The RBC count is the part of the CBC
that determines the number of RBCs
found in a cubic centimeter of blood.
It is also expressed in International
Units, which is the number of RBCs
per liter of blood. Electronic
automated devices perform the test.
Although the total RBC count does
give information about the oxygen-
carrying capacity of blood, Hgb and
Hct provide more precise
information. See Table 9 for normal
values.
Hemoglobin
As previously mentioned, Hgbs
primary func-tion is to carry oxygen
to the cells and remove carbon
dioxide from the cells. Hgb is a
complex protein made up of heme
and globin. It is produced in the
immature RBC. Synthesis stops once
the cell matures in circulation. There
are approximately 300 million
molecules of Hgb in one RBC. Hgb is
measured in grams per decili-ter. See
Table 10 for normal values.

The heme portion contains iron atoms

and the red pigment, porphyrin. The
heme portion is responsible for the
red color of blood. When the RBC is
saturated with oxygen, the red color
is brightest. The globin portion is
made up of 4 amino acid chains. One
heme molecule at-taches to each of
the 4 amino acid chains. Therefore,
each Hgb molecule has 4 heme sites
that can bind with 4 oxygen
molecules. A Hgb
 GEORGE-GAY AND The RBC count, Hct, and Hgb are
PARKER closely re-lated. Alterations in one
are usually associated
Table 10. Hemoglobin
Table 11. Hematocrit

Adult male
Adult female

is considered fully saturated when it

contains 4 oxygen molecules. Hgb
saturated with oxygen is called
oxyhemoglobin. One should note that
oxygen saturation is a measure of the
amount of oxygen combined with Hgb
in the blood and should not be
confused with the partial pres-sure of
oxygen (PO2), which is the amount of
oxygen dissolved in plasma. Hgb also
functions as a buffer for extracellular
fluid and is capable of accepting
hydrogen (H ) ions to prevent the
buildup of H ions in the blood.
Hematocrit
Hct represents the percentage of the
total vol-ume of RBCs relative to the
total volume of whole blood in a
sample. Hematocrit means to
separate blood. With todays method
of automated cell counting, Hct is
calculated rather than centrifuged.
See Table 11 for normal values. The
surgeon and anesthesia provider
must be notified for values of less
than 20% or greater than 60%.
Swelling of the RBC secon-dary to
hyperglycemia or hypernatremia may
produce an elevated Hct. Excessively
elevated WBC counts may also alter
the Hct.

Hgb and Hct levels parallel, in that

Hct levels are 3 times the Hgb level.
To estimate values, you would divide
the Hct by 3 to estimate the Hgb, and
multiply the Hgb by 3 to estimate the
Hct. This relationship is altered if
RBCs are abnormal in size or shape
or if the synthesis of Hgb is defective.
Adult male
Adult female
UNDERSTANDING THE CBC WITH DIFFERENTIAL

with alterations in the other. As such,

increases and decreases in each are
discussed together.
Increased Levels
An increase in the number of RBCs
can be described as either
erythrocytosis or polycythe-mia. In
the clinical setting, the terms are fre-
quently used as synonyms. The term
erythrocy-tosis, however, more
accurately defines an elevated RBC
count, whereas the term polycy-
themia more accurately refers to a
specific group of disorders. These
disorders can be de-scribed as either
primary polycythemia or sec-ondary
polycythemia.
Decreased Levels
Decreased levels of RBCs, Hgb, and
Hct are associated with hemodilution
and anemia. He-modilution occurs as
plasma volume increases from fluid
therapy. Anemia is a reduction in the
total number of circulating RBCs or a
decrease in the quality or quantity of
Hgb or in the volume of packed cells
(Hct). Nutritional ane-mias or
anemias caused by chronic diseases
are caused by iron, folate, and
vitamin B12 deficien-

Primary polycythemia (vera) is an

increase in the number of RBCs
secondary to a relatively rare
myeloproliferative disease of the bone
mar-row involving the excessive
production of red cell precursors.
Secondary polycythemia de-scribes
an increase in RBCs as a physiologic
compensatory mechanism (via
erythropoietin) for decreases in
oxygen delivery as seen in
cardiopulmonary diseases such as
congestive heart failure (CHF),
cardiovascular malforma-tion, and
chronic obstructive pulmonary dis-
ease, as well as in those living in high
altitudes.

Dehydration also causes a relative

increase in RBC, Hgb, and Hct
because of a decrease in plasma
volume. This is clinically referred to
as hemoconcentration and may be
seen frequently in the perianesthesia
setting. Other causes in-clude
excessive exercise, anxiety, pain, and
cer-tain drugs such as gentamycin
and methyldopa (Aldomet), as well as
with renal and liver tu-mors.
cies. Acute anemias are caused by
blood loss due to hemorrhage, or by
RBCs being destroyed faster than the
normal bone marrow can re-place
them. Extreme RBC destruction
occurs in conditions such as
hemolytic or type II hyper-sensitivity
blood transfusion reactions (hemoly-
sis of RBCs because of ABO
incompatibility). Other conditions
causing anemia are those that alter
erythropoiesis such as renal failure,
chemo-therapeutic agents (by
suppressing the bone marrow), and
leukemia. Hemoglobinopathies (such
as sickle cell anemia) and the
thalassemias are also causes of
anemia. Age also plays a role in
anemia because there is a tendency
for lower values in people over the
age of 50. Lastly, during pregnancy
there is a relative anemia as the
normal number of RBCs becomes
diluted from the increase in body
fluid that occurs during pregnancy.
Although all types of anemia will be
seen in the perianesthesia setting, the
most common cause of decreased
RBC, Hgb, and Hct levels overall is
blood loss or hemorrhagic anemia.
112
Table 12. RBC Indices
Adult
MCV
MCH
MCHC
RBC Indices
RBC indices are calculated mean
values that are used to define the
size, weight, and Hgb con-tent of the
RBC. They are mainly used to classify
anemias. RBC indices consist of mean
corpus-cular volume (MCV), mean
corpuscular hemo-globin (MCH), and
Red cell transfusion is almost always
indicated for a Hgb less than 6 g/dL
and rarely indicated for Hgb greater
than 10 g/dL. Once the Hgb level falls
below 11 g/dL in an otherwise
healthy adult, the kidney will begin to
secrete increasing amounts of
erythropoietin in a matter of hours.
Unfortunately, it will take 3 to 6 days
before a rise in circulating RBCs will
be noted. However, the decision to
transfuse should never be dic-tated
by a single Hgb trigger.15
Other RBC Values
Reticulocyte Count
The reticulocyte is an immature RBC
found in the bone marrow (Fig 1).
There is a small per-centage of
reticulocytes released into the blood
stream that accounts for
approximately 0.5% to 1.5% of the
total RBC count. An increased count
indicates the bone marrow is
attempting to replace sudden RBC
loss from hemorrhage or destruction.
A decreased count would indicate
bone marrow hypofunction. This
count is nor-mally increased in
pregnancy.
mean corpuscular hemoglo-bin
concentration (MCHC). See Table 12
for normal values.
Mean corpuscular volume. MCV
describes the RBC by size or volume.
This measure uses the size of the
RBC to identify possible causes of
anemia as well as other disorders.
The MCV classifies RBCs as
microcytic, normocytic, and
macrocytic. Microcytic cells are small
or un-dersized. They are seen with
iron deficiency anemia and
thalassemia. In hemorrhagic or
hemolytic anemias, the decrease in
oxygen-carrying capacity is caused by
a decrease in the number of RBCs;
the cells that remain are normal in
size, thus the RBCs are normocytic.
RBCs that are macrocytic are large or
over-sized. These RBCs are seen in
patients with pernicious or folate
deficiency anemia. MCV is a measure of the average concentration
calculated value obtained by dividing
the Hct by the RBC count.
Mean corpuscular hemoglobin. This
value is the index that measures the
average weight of Hgb in the RBC. An
alteration in MCH tends to track
along with the MCV. For example, a
small-sized cell will have less Hgb
within it compared with a large-sized
cell, therefore its weight would be
lower. Decreases are related to micro-
cytic anemias, and elevations are
related to mac-rocytic anemias.
Therefore, the MCH adds little
information independent of the MCV.
GEORGE-GAY AND
PARKER
Mean corpuscular hemoglobin
concentra-tion. This index is a
of Hgb in the RBC per unit volume.
RBCs that contain less Hgb are hypo-
chromic and are a pale color. Normal-
colored cells with normal amounts of
Hgb are called normochromic, and
hyperchromic cells have an increased
concentration of Hgb and are bright
red in color.16
Nursing Implications
Polycythemic patients need to be
monitored for signs and symptoms of
thrombus formation. Patients should
be monitored closely for com-plaints
of leg pain, changes in color,
tempera-ture, and capillary refill in
addition to initiating VTE prophylaxis
(Table 8) and ensuring ade-quate
fluid administration. Sudden
restlessness, anxiety, and dyspnea
may herald a pulmonary embolus.
Changes in a patients level of con-
sciousness or neurologic examination
can warn of diminished cerebral
blood flow and warn of the potential
for stroke.
Anemic patients are at additional risk
anytime they must undergo surgical
procedures. Be sure to request a type
and crossmatch to ensure that
patient-compatible blood will be
available in the blood bank. Be alert
to signs of blood loss, including but
not limited to hypotension, tachy-
cardia, restlessness, hypoxia, chest
pain, fa-tigue, and occult blood
positive stools and gas-tric
specimens. In the preanesthesia
setting, the decision to transfuse the
patient with Hgb be-tween 6 and 10
g/dL should be based on indi-vidual
risk, such as type and extent of the
surgery, the ability to control the
bleeding, and the rate of uncontrolled
bleeding. For elective procedures,
Hgb of 10 g/dL or greater is recom-
mended. Preoperative Hgb below 10
g/dL is an indication to postpone an
elective case. If blood transfusion is
required, expect the Hgb to rise by 1
g and the Hct by 3% for each unit of
packed RBCs transfused.

Patient care activities may need to be

delivered in such a way as to reduce
the patients fatigue, metabolic
demand, and physical stress. Contin-
UNDERSTANDING THE CBC WITH DIFFERENTIAL

uous pulse oximetry is required to foods that are extremely cool or hot
monitor for hypoxia. Be prepared to in temperature. Jaundiced patients
provide supplementary oxygen and to will require comfort measures and
promote adequate lung expan-sion medications to reduce the discomfort
through optimal patient positioning. associated with itching.
Also use pulmonary hygiene
strategies and teach pa-tients to Platelets (Thrombocytes)
perform turn, cough, and deep breath Platelets are the smallest of the cells
exercises. found in blood. They are
nonnucleated, flattened disk-shaped
Closely monitor intake and output in structures that can be round or oval.
patients with Hgb counts below 7 to 8 They have a lifespan of 9 to 12 days.
g/dL. Blood flow to the kidneys is
diminished in these states, and the
patient is at risk for oliguria. Secure
and maintain intravenous access for
these patients. Additionally, provide
passive or active warming measures
because patients will complain of cold
and be pale in color.

RBC indices assist in classifying

anemias. In general, be sure to fully
assess a patients nutri-tional status
and consult a dietitian for further
workup and intervention as
appropriate. Wound healing can be
grossly affected by nu-tritional
anemias, and patients may require
iron, zinc, and vitamin C supplements
to promote surgical wound healing.
Patients will also re-quire teaching
and need encouragement to in-clude
iron-rich foods such as liver, red
meat, raisins, peas, apricots, kidney
beans, and forti-fied cereals and
breads in their diets.

Increased RBC indices indicate an

increased number of circulating
immature RBCs in the peripheral
circulation, increasing the patients
likelihood of jaundice, stomatitis, and
glossitis. Attention to mouth care will
be essential. The use of soft bristle
toothbrushes and cool, alka-line
mouthwash is recommended. The
patient should be informed to avoid
sour, tart, and spicy foods, as well as
Platelets play a vital role in
hemostasis; they, along with the
coagulation factors, are respon-sible
for hemostasis in small and medium-
size arteries and veins. Platelets
aggregate or stick together to form
the initial plug where there is
damaged endothelium. Clotting
factors are then triggered to form
fibrin strands throughout the plug to
firmly hold the plug together. For the
capillaries, platelets plug and stop
bleeding by themselves, thereby
sealing the multitude of minute
ruptures that occur on a daily basis. A
platelet plug forms within 3 to 5
minutes.
The platelet count only provides the
number of circulating plates; it does
not describe how adequately they
function. The most indicative test of
platelet function is the bleeding
time.
Increases in the platelet count or
thrombocyto-sis are usually
asymptomatic until counts reach
greater than 1,000,000 m/L, where
increased viscosity and inappropriate
clotting may occur. A transient
thrombocytosis with platelet counts
of 450,000 to 600,000 m/L can be
114
advocating for the postponement of
surgical procedures and prepare for
possible plate-let transfusion. Platelet
transfusion is recom-mended
prophylatically for the surgical
patient with a platelet count of less
than 50,000 m/L who is undergoing a
major procedure. Platelet transfusion
may also be indicated if there is
known platelet dysfunction and
microvascular bleeding despite
16
adequate counts. For each
concentrate of platelets transfused,
expect the platelet count to increase
by 5,000 to 10,000 m/L. Keep in mind
that one aspirin will coat the platelet,
seen as a physiologic response to
physical stress, exer-cise, trauma,
infection, and ovulation. Counts
greater than 600,000 m/L may be
associated with myeloproliferative
disorders of the stem cells in the
bone marrow.
Thrombocytopenia or decreased
platelet count is defined as a count of
less than 150,000 m/L. Causes
include depressed production by the
bone marrow or increased
consumption or de-struction as seen
with idiopathic thrombocyto-penia.
Bleeding usually does not occur until
counts fall below 50,000 m/L if
platelets are functioning normally.
Small hemorrhagic areas under the
skin called purpura may occur at this
level.
Nursing Implications
Patients with known
thrombocytopenia are at risk for
bleeding, especially when counts fall
below 50,000 m/L. Counts under
20,000 m/L significantly increase the
risk for mortality sec-ondary to
hemorrhagic stroke or gastrointesti-
nal hemorrhage.16 In these instances,
consider
preventing it from aggregating for
the life of that platelet. A
preoperative aspirin may be more
important than platelet count in ex-
plaining a bleeding disorder.
Remember that thrombocytosis
commonly oc-curs after hemorrhage
and surgical procedures.
 GEORGE-GAY AND It is clear that the needs of patients
PARKER in the perianesthesia setting are
driven by the context of their
Counts soon return to normal limits
respective surgical treatment plans.
once the patient recovers from the
These needs become complex when
primary insult. The need for VTE
integrated with the magnitude of
prophylaxis (Table 8) for patients with
premorbid conditions and drug
increased platelet counts also exists.
profiles that exist for each individual
Pa-tient teaching should include
patient. Knowledge of a patients
precautions to minimize the risk for
premorbid state and medications
infection and bleeding in postsurgical
should heighten the cli-nicians
recovery period.
awareness and analysis of specific
Summary CBC and differential results.

References
1. Chernecky C, Berger BJ (eds): Laboratory Tests 8. Catalano P: White blood cell count with
and Diag-nostic Procedures (ed 3). Philadelphia, PA, differential, in George-Gay B, Chernecky C (eds):
Saunders, 2001, pp 372-376 Clinical Medical-Surgical Nursing. Philadelphia, PA,
2. Centers for Medicare and Medicaid Services Saunders, 2002, pp 282-290
(CMS): Na-tional Coverage Determinations for 9. Sadovsky R: WBC predicts increased mortality
Blood Counts. Available at in acute MI. Am Fam Physician 64:1261, 2001
www.cms.hhs.gov/ncd/searchdisplay.asp?NCD_ID 10. Koch-Kubetin S: WBC Count Predicts Stroke.
61&NCD_ vrsn_num 1. Accessed December 2002. OB GYN News. 25:24, 2000
3. Goodnough LT, Brecher ME, Katner MH, et al: 11. Tresler KM: Hematology screen, in Clinical
Transfusion medicine: Blood transfusion. N Engl J Laboratory Diagnostic Tests Significance in Nursing
Med 340:438-447, 1999 Implications (ed 3). Norwalk, CT, Appleton Lange,
4. Medicare Part B Model Local Medical Review 1995
Policy, Sub-ject: Blood counts. Avera Health Lab
12. Abramson N, Melton B: Leukocytosis: Basics
News. 4:2-4, 2000. Available at
of clinical assessment. Am Fam Physician 62:2053-
www.averalabnet.com/newsletters/NewsJanFeb00.h
2060, 2000
tm. Ac-cessed December 2002
13. Gawlikowski J: White cells at war. Am J Nurs
5. Cannon CP, McCabe CH, Wilcox RG, et al:
92:44-51,
Association of white blood cell count with increased
1992
mortality in acute myo-cardial infarction and
unstable angina pectoris. Am J Cardiol 87:636-639, 14. The ABCs of CBC: A common blood test. Mayo
2001 Clinic Health Letter, August 2001, pp 4-5
6. Baylor College of Medicine: Geriatric 15. American Society of Anesthesiologists:
assessment, medical assessment, laboratory work- Practice Guide-lines for Blood Component Therapy.
up. Available at www.geri-ed. Available at www.asahq.
com/modules/Asses/assess/medical_assessment.htm. org/practice/blood/blood_component.html. Accessed
Accessed December 2002 December 2002
7. Banasik JL: Inflammation and Immunity, in 16. Garrett K: Red blood cell counts, in George-
Copstead LC, Banasik JL (eds): Pathophysiology Gay B, Chernecky C (eds): Clinical Medical-Surgical
Biological and Behavioral Per-spectives (ed 2). Nursing. Philadel-phia, PA, Saunders, 2002, pp 274-
Philadelphia, PA, Saunders, 2000, pp 184-218 282
UNDERSTANDING THE CBC WITH DIFFERENTIAL

Understanding the Complete Blood Count With

Differential 1.4 Contact Hours
Directions: The multiple-choice examination below is designed to test your
understanding of the Complete Blood Count With Differential according the objectives
listed. To earn contact hours from the American Society of PeriAnesthesia Nurses
(ASPAN) Continuing Education Provider Program: (1) read the article; (2) complete the
posttest by indicating the answers on the test grid provided; (3) tear out the page (or
photocopy) and submit postmarked before February 28, 2005, with check payable to
ASPAN (ASPAN member, $12.00 per test; nonmember, $15.00 per test); and (4) return
to ASPAN, 10 Melrose Ave, Suite 110, Cherry Hill, NJ 08003-3696. Notification of
contact hours awarded will be sent to you in 4 to 6 weeks.

Posttest Questions
1. In the process of erythropoiesis, iron is needed for
a. hemoglobin synthesis.
b. DNA synthesis.
c. reproduction.
d. renal excretion.
2. When monitoring a patient who is not bleeding, the nurse would expect to
find an increase in Hct of 3% after a transfusion of one unit of packed RBCs.
a. True
b. False
3. The amount of blood combined with Hgb is a measurement of
a. partial pressure of oxygen (PaO2).
b. arterial-venous oxygen difference.
c. oxyhemoglobin.
d. oxygen saturation (SaO2).
4. In an adult patient with normal Hgb, the nurse will estimate the Hgb to be
10 g/dL if the Hct was reported to be 30%.
a. True
b. False
5. Secondary physiologic polycythemia is caused by all of the following except
a. congestive heart failure.
b. renal failure.
c. high altitudes.
d. chronic obstructive pulmonary disease.
6. Pernicious anemia is caused by
a. alcoholism.
b. chronic blood loss.
c. vitamin B12 deficiency.
d. iron deficiency.
7. An elevated reticulocyte count would be expected in
a. a recovering trauma patient who lost significant amounts of blood.
b. a patient with a chronic inflammatory disease.
116 GEORGE-GAY AND
PARKER

c. a patient in renal failure.

d. a patient with bone marrow hypofunction.
8. All of the following are included in the CBC except
a. erythrocyte sedimentation rate.
b. neutrophil count.
c. platelet count.
d. bands.
9. A CBC is indicated for patients greater than age 65.
a. True
b. False
10. Shift to the right means that
a. there is an elevation in bands.
b. the patient probably has an acute viral infection.
c. an acute hypersensitivity reaction is occurring.
d. hypermature segmented neutrophils are present.
11. Neutropenic precautions involves all of the following except
a. reverse isolation.
b. staying away from children recently vaccinated.
c. reporting temperatures of greater than 38C.
d. avoiding indiscriminate use of acetaminophen.
12. The major cell of the immune response is the
a. cytotoxic T cell.
b. B cell.
c. plasma cell.
d. helper T cell.
13. Nutritional anemias as recognized in the RBC indices can assist in
identifying patients
a. at risk for allergic reactions.
b. in need of postoperative blood transfusion.
c. at risk for poor wound healing.
d. none of the above.
14. Once Hgb levels fall below 11 g in an otherwise healthy adult, the kidney
will begin to secrete erythropoietin in a matter of hours. A rise in
circulating red blood cells will be noted within

a. 6 to 8 days.
b. 3 to 5 days.
c. 24 hours.
d. 48 hours.
15. Venous thromboembolism prophylaxis is required for patients with total
WBC counts greater than 100,000.
a. True
 b. False
UNDERSTANDING THE CBC WITH DIFFERENTIAL

ANSWERS
System W010405. Please circle the correct answer
1. a.
b.
c.
d.
6. a.
b.
c.
d.
11. a.
b.
c.
d.

Please Print

Name

Address

City

Social Security

EVALUATION: Understanding the Complete Blood Count With Differential (SD,

strongly disagree; D, disagree; ?, uncertain; A, agree; SA, strongly agree)

1. To what degree did the content meet the

objectives?
a. Objective #1 was met.
b. Objective #2 was met.
c. Objective #3 was met.
d. Objective #4 was met.
e. Objective #5 was met.
f. Objective #6 was met.
2. The program content was pertinent,
comprehensive, and useful to me.
3. The program content was relevant to my
nursing practice.
4. Self-study/home study was an appropriate
format for the content.
5. Identify the amount of time required to read the
article and take the test.
25 min 50 min 75 min 100 min 125 min

Test answers must be submitted before April 30, 2005, to receive contact hours.