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Cancer of the blood: Leukemia

Leukemia is a primary disorder of the bone marrow in which the normal elements are replaced with abnormal
white blood cells.( Unrestricted Proliferation of immature while blood cells in the blood). Leukemia is the most
common form of childhood cancer. ♦Proliferation: increase in number of cells as a result of cells division or

 Normally:
*Lymphoid cells grow and develop into lymphocytes.

*Myeloid cells grow and develop into red blood cells, granulocytes, monocytes,and platelets.

 Leukemia may develop at any time during the usual stages of normal lymphoid or myeloid
development. Leukemia may be classified as acute or chronic, lymphocytic or myelogenous .
 Acute leukemias are rapidly progressive diseases affecting the undifferentiated or immature
cells, production of an excessive number of immature (still in the stem, or “blast,” stage) white blood cells (WBCs);
the result is cells without normal function.
 Chronic leukemias progress more slowly, permitting maturation and differentiation of cells so
that they retain some of their normal function.
 Acute leukemias account for about 95%of all cases of leukemia in children and adolescents
including :
1. Acute lymphoblastic leukemia (ALL).
2. Acute myelogenous leukemia (AML).
 The primary difference is the type of leukocyte (WBC) involved.
- In ALL, the immature WBCs are lymphocytes.
- In AML the WBCs involved are cells from the myeloid line, primarily granulocytes or monocytes.

Complications of leukemia include metastasis to the blood, bone, CNS, spleen, liver, or other organs and
alterations in growth. Late effects include problems with neurocognitive function and ocular, cardiovascular, or

thyroid dysfunction. With advances in treatment over the past 50 years, most cases of childhood leukemia are
curable, though children who experience relapse or present with advanced disease have a poorer prognosis.

Clinical Manifestation: Diagnosis suspected by history and physical data. Onset described as acute to vague
(insidious) with few symptoms.

• Cold that does not resolve completely.

• Pallor, fatigue, restlessness, irritability, and anorexia may be noted.
• Fever (may be persistent or recurrent, with unknown cause).
• Recurrent infection.
• Unusual bleeding or bruising.
• Abdominal pain.
• Nausea or vomiting.
• Bone pain. Headache.
Pathology and clinical manifestation of the disease are caused by infiltration and replacement of any tissue of the
body with nonfunctional leukemic cell.
The pathologic process and related clinical manifestations in the most susceptible organs of the body:

I) Bone marrow dysfunction: the proliferating cells depress bone marrow production of the formed
elements of the blood by competing for and depriving the normal cell of the essential nutrients for metabolism. This
will lead to the following pathologic results:
a. anemia due to decrease erythrocytes production.
b. infection from neutropenia.
c. bleeding tendencies due to decreased platelets.
 Invasion of bone marrow with leukemic cells causes weakening of the bone and easily fractures.
 Hepatospleenomegally due to marked infiltration of leukemic cells.
 CNS system involvement causes leukemic meningitis manifested by signs and symptoms of increase
intra cranial pressure. Hydrocephalus and blindness may occur.
 Changes in behavior or personality, headache, irritability, dizziness, persistent nausea or vomiting,
seizures, gait changes, lethargy, or altered level of consciousness may indicate CNS infiltration with leukemic cells.

II) Hypermetabolism:

Metabolic needs of proliferating leukemic cells deprive all body cells of nutrients necessary for survival lead to
muscle wasting, weight loss, anorexia and fatigue are natural consequences pale, fever, bone, and joint pain.

Diagnosis: leukemia confirmed by bone marrow aspiration or biopsy.

Test Results

• Abnormal complete blood counts: low hemoglobin and hematocrit, decreased red blood cell count,
decreased platelet count, and elevated, normal, or decreased WBCcount.
• Peripheral blood smear may reveal blasts immature leukocytes.
• Stained smear from bone marrow aspiration will show greater than 25% lymphoblasts. Bone marrow
aspirate is also examined for immunophenotyping (lymphoid vs.myeloid, and level of cancer cell maturity).
• Immunophenotyping and cytogenetic analysis are used in the classification of the leukemia,which helps
guide treatment.
* Cell-surface immunologic markers can be used to identify type of cell involved. The common ALL antigen
(CALLA)-positive children have best survival rate.

• Lumbar puncture will reveal whether leukemic cells have infiltrated the CNS.
• Liver function tests and blood urea nitrogen (BUN) and creatinine levels determine liver and renal
• Chest x-ray may reveal pneumonia or a mediastinal mass.
• Chest CT scan and bone scans to detect metastasis to lung.

Therapeutic management:

o Therapeutic management of the child with ALL focuses on giving chemotherapy to eradicate the
leukemic cells and restore normal bone marrow function.
o CNS prophylaxis is provided at each stage; without CNS prophylaxis, leukemia would spread to the
CNS in up to 50% of children with ALL.
o The length of treatment and choice of medications are based on the child’s age, risk category, and
subtype determined by bone marrow analysis.
 Bone marrow transplantation (BMT) used to treat children with ALL and AML:
- Reserved for second remission with ALL.
- May be used with first AML remission to improve prognosis.
 Radiotherapy to destroy tumor.

Nursing Interventions

 Preventing infection
 Assess for fever, pain, cough, tachypnea, adventitious breath sounds, skin ulceration, stomatitis, and
perirectal fissures to identify potential infection.
 Administer antibiotics for temperature >38.4°C to decrease likelihood of over whelming sepsis. Low
temperature is a sign for sepsis also.
 As neutrophils are the primary means of fighting bacterial infection, when the neutrophil count is low,
the chance for developing an overwhelming bacterial infection is high.
 Maintain meticulous hand washing procedures (include family, visitors, staff) to minimize spread of
infectious organisms.
 Maintain isolation as prescribed to minimize exposure to infectious organisms. Use Protective isolation,
chemotherapy is immunosuppressive, so they are prone to infections.
 Avoid rectal temperatures and examinations, intramuscular injections, and urinary catheterization when
child is neutropenic to decrease possibility of introducing microorganisms.
 Educate family and visitors that child should be restricted from contact with known infectious
exposures (in hospital and at home) to encourage cooperation with infection control. Put face mask for the child to
prevent infection transmission.
 Strictly observe medical asepsis to avoid unintentional introduction of microorganisms.
 Promote nutrition and appropriate rest to maximize body’s potential to heal.
 Administer vaccines (not live) as prescribed (after consultation with oncologist) to prevent common
childhood communicable diseases.
 Teach family to monitor for fever at home and report temperature elevations to oncologist immediately,
so that antibiotic therapy may be instituted as soon as possible.

 Promoting comfort
 Determine level of pain using child interview, pain scale, and assessment of physiologic variables to
determine baseline.
 Document location, intensity, description of pain to determine baseline.
 Discuss with the child and parent techniques that have helped alleviate pain in the past to incorporate
successful interventions into the plan of care.
 Administer acetaminophen for mild pain (avoid salicylate and non-steroidal anti-inflammatory drugs
due to increased risk for bleeding).
 Administer medications as ordered using the least invasive method possible to avoid pain
(intramuscular, subcutaneous, and rectal route should be avoided in the child withthrombocytopenia).
 Monitor frequently for adverse effects (particularly respiratory effects) of opioid analgesics, as opioids
reduce responsiveness of carbon dioxide receptors in the brain’s respiratory center.
 Use non pharmacologic measures such as play therapy, games, TV, guided breathing,imagery, hypnosis,
or meditation as appropriate (distracts child’s attention from the pain).
 Use massage, positioning, or heat to relieve pain in a particular area.
 Use EMLA before needle sticks and conscious sedation with lumbar puncture and bone marrow
aspiration to reduce recurrent acute painful episodes associated with frequent blood draws and diagnostic/treatment
 Have the child lie flat for 30 minutes after a lumbar puncture and increase fluid intake for24 hours after
the procedure to decrease incidence of headache.

 Family and child care:
 Preparation of family, child for diagnostic procedure e.g. L.P, bone marrow.
 Provide emotional support to child and family (improves coping abilities).
 Actively listen to the child’s and family’s concerns (validates their feelings, establishes trust).
 Provide open communication with the child and siblings; children appreciate honesty about their
illness, and coping is improved.
 Refer families to community resources such as parent support groups and grief counseling (such
support improves coping abilities).
 Use therapeutic communication with open-ended questions to encourage an open and trusting
relationship for better communication.
 Actively listen to family’s expression of grief; just being present and listening conveys support.
 Encourage the family to cry and express feelings away from the child to work through feelings while
not upsetting the child.
 Educate the family about the child’s condition honestly.

 Hemorrhage: platelets below 20,000 mm/dl.

 Care of puncture site.
 No aspirin.
 Mouth care gingival bleeding.
 Rectal care, no rectal temperature.
 Administer blood products, (platelets).
 Skin care.

 Manage Problems associated with radiation and chemotherapy

1. Nausea and vomiting:

 Administer antiemetic prior to chemotherapy and as needed (PRN) to decrease frequency of nausea.
 Assess frequency of vomiting and level of hydration to provide baseline data and recognize alterations
 Offer frequent, smaller meals or snacks; smaller amounts are less likely to be vomited.
 Avoid spicy foods to avoid stomach upset.
 Allow bubbles to dissipate from carbonated beverages before they are ingested
(carbonation may contribute to nausea).

 Remove cover from meal tray before entering child’s room (this will allow the food odor to dissipate
outside of the room; food odors may trigger nausea and vomiting)

2. promoting adequate nutrition, improve anorexia:

 Determine body weight and length/height norm for age or find out what the child’s pretreatment
measurements were to determine goal to work toward.
 Determine child’s favorite food and preferences.
 Administer anti emetics as ordered to increase the likelihood that the child will retain the food he
 Weigh child daily or weekly and measure length/height weekly to monitor for growth.
 Offer highest-calorie meals at the time of day when the child’s appetite is the greatest (to increase
likelihood of increased caloric intake).

 Provide increased-calorie shakes or puddings within diet restriction (high calorie foods increase weight
 Administer vitamin and mineral supplements as prescribed to attain/maintain vitamin and mineral
balance in the body.
 Administer total parenteral nutrition and intravenous lipids as ordered to provide adequate nutrition for

3. Mucosal ulceration
 Frequently assess oral cavity for redness, lesions, ulcers, plaques, or bleeding
 to provide baseline for comparison and identify alterations early.
 Offer ice chips frequently while NPO to maintain hydration of mucosa.
 Soft tooth brush, to decrease incidence of bleeding with mouth care.
 Keep lips lubricated with petroleum jelly to maintain moist, hydrated lips.
 Rinse with salt solution or mouthwash every 1 to 2 hours to keep oral cavity clean and moist.
 Administer glutamine and/or beta-carotene supplements, which have been shown to decrease the
incidence and severity of mucositis.
 Administer antifungal solution to prevent or treat oral candidiasis.
 Avoid spicy, acidic, or very hot or very cold foods; give soft diet to decrease pain.
 Administer pain medication (usually acetaminophen or codeine) as ordered to decrease pain.

4. Peripheral neuropathy.
 Severe constipation.
 Foot drop.
 Numbness of extremities.

Preventing or managing constipation

 Ensure that child increases fluid intake to provide enough water in the intestines for soft stool
 Increase fiber in the diet to provide bulk for stool formation.
 Administer stool softeners such as mineral oil, docusate sodium; these help soften the stool, aiding in
 Use stimulant laxatives such as senna or bisacodyl only intermittently rather than on a daily basis to
avoid dependency and diarrhea.

5. Hemorrhagic cystitis: noninfectious inflammation of the bladder leading to dysuria, hematuria, and
hemorrhage. The disease can occur as a complication of chemotherapy: (cyclophosphamide, ifosfamide) and
radiation therapy.Notify medical doctor, and maintain hydration.Stop drug.

6. Alopecia (loss of hair).

7. Moon face from cortisone use.
♣Tumor lysis syndrome: cell death, high level of uric acid is excreted during chemotherapy.Associated with
Nausea, vomiting, diarrhea, anorexia, Lethargy,increased heart rate and blood pressure, decreased or absent urine
output, altered level of consciousness
Lab tests:
 Hyperuricemia
 Hyperkalemia
 Hyperphosphatemia
 Hypocalcemia, and Hypoxia.

Prevent Tumor lysis syndrome by:
 giving allopurinol for several days prior to chemotherapy(also treat with allopurinol).Allopurinol
reduce formation of uric acid
 Double IV fluid maintenance to make washing out.
 Give Sodium bicarbonate