RBC Count, Indices, Morphology, and Inclusions
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RBC Count: To evaluate the number of circulating red cells in the blood toward diagnosing disease and monitoring therapeutic treatment. RBC Indices: To evaluate cell size, shape, weight, and hemoglobin (Hgb) concentration. Used to diagnose and monitor therapy for diagnoses such as iron-deficiency anemia. Variations in the number of cells is most often seen in anemias, cancer, and hemorrhage. Morphology and Inclusions: To make a visual evaluation of the red blood cell (RBC) shape and/or size as a confirmation in assisting to diagnose and monitor disease progression.
There are no food, fluid, activity, or medication restrictions unless by medical direction.
Method: Automated, computerized, multichannel analyzers; microscopic, manual review of stained blood smear.
|Age||Conventional Units (106 cells/microL)||SI Units (1012 cells/L) (Conventional Units × 1)|
|7 mo–15 yr||3.81–5.21||3.81–5.21|
|Values are decreased in pregnancy related to the dilutional effects of increased fluid volume and potential nutritional deficiency related to decreased intake, nausea, and/or vomiting. Values are slightly lower in older adults associated with potential nutritional deficiency.|
|Age||MCV (fL)||MCH (pg/cell)||MCHC (g/dL)||RDWCV||RDWSD|
|MCV = mean corpuscular volume; MCH = mean corpuscular hemoglobin; MCHC = mean corpuscular hemoglobin concentration; RDWCV = coefficient of variation in red blood cell distribution width; RDWSD = standard deviation in RBC distribution width.|
|RBC Morphology and Inclusions|
|RBC Morphology||Within Normal Limits||1+||2+||3+||4+|
|Anisocytosis||0–5||5–10||10–20||20–50||Greater than 50|
|Macrocytes||0–5||5–10||10–20||20–50||Greater than 50|
|Microcytes||0–5||5–10||10–20||20–50||Greater than 50|
|Poikilocytes||0–2||3–10||10–20||20–50||Greater than 50|
|Burr cells||0–2||3–10||10–20||20–50||Greater than 50|
|Acanthocytes||Less than 1||2–5||5–10||10–20||Greater than 20|
|Schistocytes||Less than 1||2–5||5–10||10–20||Greater than 20|
|Dacryocytes (teardrop cells)||0–2||2–5||5–10||10–20||Greater than 20|
|Codocytes (target cells)||0–2||2–10||10–20||20–50||Greater than 50|
|Spherocytes||0–2||2–10||10–20||20–50||Greater than 50|
|Ovalocytes||0–2||2–10||10–20||20–50||Greater than 50|
|Stomatocytes||0–2||2–10||10–20||20–50||Greater than 50|
|Drepanocytes (sickle cells)||Absent||Reported as present or absent|
|Helmet cells||Absent||Reported as present or absent|
|Agglutination||Absent||Reported as present or absent|
|Rouleaux||Absent||Reported as present or absent|
|Hypochromia||0–2||3–10||10–50||50–75||Greater than 75|
|Adult||Less than 1||2–5||5–10||10–20||Greater than 20|
|Newborn||1–6||7–15||15–20||20–50||Greater than 50|
|Cabot rings||Absent||Reported as present or absent|
|Basophilic stippling||0–1||1–5||5–10||10–20||Greater than 20|
|Howell-Jolly bodies||Absent||1–2||3–5||5–10||Greater than 10|
|Heinz bodies||Absent||Reported as present or absent|
|Hgb C crystals||Absent||Reported as present or absent|
|Pappenheimer bodies||Absent||Reported as present or absent|
|Intracellular parasites (e.g., Plasmodium, Babesia, Trypanosoma)||Absent||Reported as present or absent|
Critical Findings and Potential Interventions
The presence of abnormal cells, other morphological characteristics, or cellular inclusions may signify a potentially life-threatening or serious health condition and should be investigated. Examples are the presence of sickle cells, moderate numbers of spherocytes, marked schistocytosis, oval macrocytes, basophilic stippling, nucleated RBCs (if the patient is not an infant), or malarial or other parasitic organisms.
Timely notification to the requesting health-care provider (HCP) of any critical findings and related symptoms is a role expectation of the professional nurse. A listing of these findings varies among facilities.
Consideration may be given to verifying the critical findings before action is taken. Policies vary among facilities and may include requesting immediate recollection and retesting by the laboratory or retesting using a rapid point-of-care instrument at the bedside, if available.
Low RBC count leads to anemia. Anemia can be caused by blood loss, decreased blood cell production, increased blood cell destruction, or hemodilution. Causes of blood loss include menstrual excess or frequency, gastrointestinal bleeding, inflammatory bowel disease, or hematuria. Decreased blood cell production can be caused by folic acid deficiency, vitamin B12 deficiency, iron deficiency, or chronic disease. Increased blood cell destruction can be caused by a hemolytic reaction, chemical reaction, medication reaction, or sickle cell disease. Hemodilution can be caused by heart failure, chronic kidney disease, polydipsia, or overhydration. Symptoms of anemia (due to these causes) include anxiety, dyspnea, edema, hypertension, hypotension, hypoxia, jugular venous distention, fatigue, pallor, rales, restlessness, and weakness. Treatment of anemia depends on the cause.
High RBC count leads to polycythemia. Polycythemia can be caused by dehydration, decreased oxygen levels in the body, and an overproduction of RBCs by the bone marrow. Dehydration by diuretic use, vomiting, diarrhea, excessive sweating, severe burns, or decreased fluid intake decreases the plasma component of whole blood, thereby increasing the ratio of RBCs to plasma, and leads to a higher than normal hematocrit (Hct). Causes of decreased oxygen include smoking, exposure to carbon monoxide, high altitude, and chronic lung disease, which leads to a mild hemoconcentration of blood in the body to carry more oxygen to the body's tissues. An overproduction of RBCs by the bone marrow leads to polycythemia vera, which is a rare chronic myeloproliferative disorder that leads to a severe hemoconcentration of blood. Severe hemoconcentration can lead to thrombosis (spontaneous blood clotting). Symptoms of hemoconcentration include decreased pulse pressure and volume, loss of skin turgor, dry mucous membranes, headaches, hepatomegaly, low central venous pressure, orthostatic hypotension, pruritus (especially after a hot bath), splenomegaly, tachycardia, thirst, tinnitus, vertigo, and weakness. Treatment of polycythemia depends on the cause. Possible interventions for hemoconcentration due to dehydration include IV fluids and discontinuance of diuretics if they are believed to be contributing to critically elevated Hct. Polycythemia due to decreased oxygen states can be treated by removal of the offending substance, such as smoke or carbon monoxide. Treatment includes oxygen therapy in cases of smoke inhalation, carbon monoxide poisoning, and desaturating chronic lung disease. Symptoms of polycythemic overload crisis include signs of thrombosis, pain and redness in extremities, facial flushing, and irritability. Possible interventions for hemoconcentration due to polycythemia include therapeutic phlebotomy and IV fluids.