Acute Lymphocytic Leukemia

Section D Group 8

Anatomy and Physiology

Normally, the bone marrow makes blood stem cells (immature cells) that develop into mature blood cells over time. A blood stem cell may become a myeloid stem cell or a lymphoid stem cell. The myeloid stem cell develops into one of three types of mature blood cells: Red blood cells that carry oxygen and other materials to all tissues of the body. Platelets that help prevent bleeding by causing blood clots to form. Granulocytes (white blood cells) that fight infection and disease.

Anatomy and Physiology

The lymphoid stem cell develops into a lymphoblast cell and then into one of three types of lymphocytes (white blood cells): B lymphocytes that make antibodies to help fight infection. T lymphocytes that help B lymphocytes make the antibodies that help fight infection. Natural killer cells that attack cancer cells and viruses.

Anatomy and Physiology

Anatomy and Physiology

Leukocytes are white blood cells ,ade in the bone marrow that defend the body from infective organisms and foreign substances. When infection occurs, the numbers of leukocytes increase. The five types of leukocytes are neutrophils, eosinophils, basophils, monocytes and lymphocytes. Monocytes and lymphocytes are grouped together as mononuclear agranulocytes.

 Lymphocytes are important as B cells and T cells. B cells become activated by the presence of an antigen and produce antibody specific to the antigenic target. T cells are vital components of cell-mediated immunity (which does not depend on the presence of antibodies circulating in body fluids and in tissues.

Anatomy and Physiology

In ALL, too many stem cells develop into lymphoblasts and do not mature to become lymphocytes. These lymphoblasts are called leukemia cells. The leukemia cells do not work like normal lymphocytes and are not able to fight infection very well. Also, as the number of leukemia cells increases in the blood and bone marrow, there is less room for healthy white blood cells, red blood cells, and platelets. This may lead to infection, anemia, and easy bleeding.

Acute Lymphocytic Leukemia

Acute lymphocytic leukemia is an aggressive neoplasm composed of immature lymphoid cells that overwhelm the bone marrow, peripheral blood, lymphoid tissues, and sometimes viscera. Affects both children and adult but it is more common in children. It accounts for 65% of the acute leukemias in children.

Risk Factors
Having a risk factor does not mean that you will get cancer; not having risk factors doesn t mean that you will not get cancer. People who think they may be at risk should discuss this with their doctor. Possible risk factors for ALL include the following: Having a brother or sister with leukemia. Being white or Hispanic. Being exposed to x-rays before birth.

Risk Factors
Being exposed to radiation. Past treatment with chemotherapy or other drugs that weaken the immune system. Having certain changes in genes or genetic disorders, such as Down syndrome.

Etiology Is UNKNOWN but the ff are said to cause leukemia:

Genetic Influence Bone marrow damage from radiation exposure Viral pathogenesis Chemicals (Benzene & alkylating agents)

Signs and Symptoms

Fever Easy bruising or bleeding Petechiae (flat, pinpoint, dark-red spots under the skin caused by bleeding) Bone or joint pain Painless lumps in the neck, underarm, stomach, or groin Pain or feeling of fullness below the ribs Weakness, feeling tired, or looking pale Loss of appetite

Diagnostic Tests
Physical exam and history: An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient's health habits and past illnesses and treatments will also be taken.

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Complete blood count (CBC) with differential: A procedure in which a sample of blood is drawn and checked for the following: The number of red blood cells and platelets. The number and type of white blood cells. The amount of hemoglobin (the protein that carries oxygen) in the red blood cells. The portion of the sample made up of red blood cells.

Bone marrow aspiration and biopsy: The removal of bone marrow, blood, and a small piece of bone by inserting a hollow needle into the hipbone or breastbone. A pathologist views the bone marrow, blood, and bone under a microscope to look for signs of cancer.

 Bone Marrow Aspiration and Biopsy Procedure Patient Preparation Explain the procedure to the patient. A mild sedative will be given 1 hour before the test, if ordered.

 Tell the patient the test usually takes only 5 to 10 minutes and that more than one bone marrow specimen may be required. Let him know a blood sample will be collected before the biopsy for laboratory testing. Make sure the patient has signed a consent form. Check the patient for hypersensitivity to the local anesthetic.

 After confirming with the doctor, tell the patient which bone- sternum, anterior or posterior iliac crest, vertebral spinous process, ribs, or tibia will be used as the biopsy site.

Nursing Interventions While the marrow slides are being prepared, apply pressure to the biopsy site until bleeding stops. Clean the biopsy site and apply a sterile dressing. Monitor the patient s vital signs and the biopsy site for signs and symptoms of infection.

Cytogenetic analysis: A laboratory test in which the cells in a sample of blood or bone marrow are viewed under a microscope to look for certain changes in the chromosomes in the lymphocytes.

Blood chemistry studies: A procedure in which a blood sample is checked to measure the amounts of certain substances released into the blood by organs and tissues in the body. An unusual (higher or lower than normal) amount of a substance can be a sign of disease in the organ or tissue that makes it.

 Lumbar puncture: A procedure used to collect cerebrospinal fluid from the spinal column. This is done by placing a needle into the spinal column. This procedure is also called an LP or spinal tap.

 Lumbar puncture is a strict aseptic technique requiring full sterile procedures. Encourage patients to drink well before and after the procedure. Positioned the patient carefully, laying on one side in a curled up position with the lumbar spine exposed (knees drawn up to the chest). Moving the patient s back closer to the edge of the bed will make access to the lumbar spine easier. Support the patient in this position throughout the procedure.

 A small local sterile dressing is applied to the spinal site after removal of the needle. Headache is a common complaint following lumbar puncture. The patient should lay flat for 6-12 hours afterwards, as sitting up may make any headache worse.

Chest x-ray: An x-ray of the organs and bones inside the chest. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body. The chest x-ray is done to see if leukemia cells are forming a mass in the middle of the chest.

Laboratory Findings Anemia Neutropenia Thrombocytopenia Leukocytosis(10% of patients with WBC>100,000)

Normal Value Pallor, fatigue, exertional dyspnea, CHF Fever(50%), infection (<30%) Petechiae, ecchymosis, retinal hemorrhages Hepatomegaly, splenomegaly (50%), lymphadenopathy Bone pain and joint pain Leukemia cutis

Laboratory Findings Mediastinal Mass CNS involvement

Testicular involvement Elevated prothrombin time (PT), partial thromboplastin time (PTT), low fibrinogen

Normal Value Cough,hypoxia, chest pain Headache, diplopia, cranial neuropathies, particularly cranial nerves VI,VIII,papilledema,nausea,vo miting Painless testicular scrotal enlargement Intracranial bleeding,DIC

Laboratory Findings

Normal Value

Decreased levels of leukocytes, Decreased level of platelets Decreased levels of leukocytes, Decreased level of platelets

Fever, infection Uncontrolled bleeding, poor wound healing Fever, infection Uncontrolled bleeding, poor wound healing

Medical and Surgical Management

Blood transfusion BEFORE: Obtain consent from the patient. Verify the right unit of blood to be administered to the right patient after typing and cross matching. Check Vital Signs for baseline data. AFTER: Assess for possible complications such as fever, allergic reactions, hemolytic reactions, and infections

ADJUNCT THERAPY Chemotherapy - the treatment choice for acute leukemia Phases: 1. Remission Induction Therapy  This is the first phase of treatment. Its purpose is to kill the leukemia cells in the blood and bone marrow. This puts the leukemia into remission.

 Is done in the hospital, and most patients need to be in the hospital approximately for 4 weeks  To achieve complete remission within 4weeks and reestablish normal hematopoiesis as quickly as possible A complete remission is achieved when the blood and bone marrow show no evidence of persistent leukemia and blood counts have returned to normal. Examination is done on the 2nd week after treatment.

2. Post-remission Therapy

This is the second phase of treatment. It begins once the leukemia is in remission. The purpose of post-remission therapy is to kill any remaining leukemia cells that may not be active but could begin to regrow and cause a relapse. This phase is also called remission continuation therapy.

A. Consolidation/Intensification Therapy

 Intensive part of post-remission therapy  Given to strengthen remission and give direct  Treatment to CNS and sanctuary sites(CNS).

B. Maintenance Therapy  Low-dose chemotherapy  Designed to provide a prolonged period of continuation therapy  To eliminate all residual leukemia cells.

Treatment protocols for ALL tend to be complex, using a wide variety of chemotherapeutic agents

Intrathecal Chemotherapy  Treatment with drugs that are injected into the fluid surrounding the brain and spinal cord (cerebrospinal fluid).  ALL invades the CENTRAL NERVOUS SYSTEM, Prophylaxis with cranial irradiation or intrathecal chemotherapy is an integral part of the treatment plan.

NURSING RESPONSIBILITIES: Chemotherapy

 Assess fluid and electrolyte status  Anorexia, Nausea and Vomiting, altered taste, mucositis and diarrhea put patients at risk for nutritional and fluid and electrolyte disturbances.  Decrease the risk for infection and bleeding

Bone marrow transplantation:

 If your bone marrow is damaged or destroyed, it can no longer make normal blood cells. In a stem cell transplant, healthy stem cells are placed in your body through an IV to help your bone marrow start to work right.

1. Allogeneic transplantation  Client is infused with same genetic type 2. Autologous transplantation  Patient is infused with own bone marrow harvested during remission disease

3. Syngeneic

 Marrow donor is an identical twin

Nursing Responsibilitites: A.Before:  A.1 Assess the current clinical status of the disease, Nutritional assessment  A.2 Physical Examination  A.3 Organ Function tests  A.4 Psychological Evaluations  A.5 Blood tests includes assessing past antigen exposure

B. During:  B.1 Monitor patient s VS  B.2 Blood oxygen saturation  B.3 Assess for adverse effects such as fever, chills, shortness of breath, chest pain, cutaneous reactions, nausea and vomiting, hypotension/hypertension, tachycardia, anxiety and taste changes.

C. After:  C.1 Ongoing nursing assessment in the follow-up visits is essential to detect late effects of therapy after BMT, which occur 100 days or more after the procedure.  C.2 Late infection includes: Varicella Zoster infection, restrictive pulmonary abnormalities, and recurrent pneumonias.  C.3 Psychosocial Assessments

Splenectomy

 Surgical removal of the spleen. This is sometimes necessary in the emergency treatment of bleeding from a ruptured spleen and in the treatment of some blood diseases.  Splenectomy in children may diminish the immune response to infections.

 Indicated for persistent symptomatic splenic enlargement in a patient who is responsive to chemotherapy.

Nursing Intervention: I. Assess for:  Temperature elevation above 101 degrees Celsius, chills, increased pulse above 100. Low grade temperature common following splenectomy for 7-10 days.  Tachypnea, ronchi, crackles, cloudy foul smelling urine, urgency frequency, irritation ulcers of oral, vaginal or other mucosa; redness or drainage from wound or invasive sites.

II. Monitor, Describe, Record:  White blood cells increases, urine, blood and wound cultures and sensitivities. WBC of > 10,000 cu/mm positive cultures for infectious organisms.  Immunoglobulins. IgM decreases, IgG ad IgA within normal ranges indicating deficiencies.  Vital signs and temperature every four hours. Indicates presence of infection.

III. Administer:

 Antibiotics specific to identified infectious agent. Acts to destroy microorganisms by inhibiting cell wall synthesis.  Antipyretic (acetaminophen). Reduces fever by inhibiting heat-regulating center.

IV. Perform or provide:  Handwash techniques before giving care. Prevents cross-contamination.  Aseptic technique for any invasive procedures. Prevents introduction of infectious agents.  Adequate fluids, nutritional and activity support. Maintains support to prevent susceptibility to infection.

 Meticulous mouth and perineal care. Promotes comfort and care of suceptible mucosal areas

Nursing Management
Preventing infection: Frequently monitor the client for pneumonia, pharyngitis, esophagitis, perianal cellulitis, urinary tract infection, and cellulitis, which are common in leukemia and which carry significant morbidity and mortality.

Monitor for fever, flushed appearance, chills, tachycardia; appearance of white patches in the mouth; redness, swelling, heat or pain in the eyes, ears, throat, skin, joints, abdomen, rectal and perineal areas; cough, changes in sputum; skin rash. Check results of granulocyte counts. Concentrations less than 500/mm3 put the patient at serious risk for infection.

Avoid invasive procedures and trauma to skin or mucous membrane to prevent entry of microorganisms. Use the following rectal precautions to prevent infections: Avoid diarrhea and constipation, which can irritate the rectal mucosa, avoid the use of rectal thermometers, and keep perineal are clean. Care for the patient in private room with strict hand washing practice.

Encourage and assist patient with personal hygiene, bathing, and oral care.

Preventing and Managing bleeding: Watch for signs of minor bleeding, such as petechiae, ecchymosis, conjunctival hemorrhage, epistaxis, bleeding gums, bleeding at puncture sites, vaginal spotting, heavy menses Be alert for signs of serious bleeding, such as headache with change in responsiveness, blurred vision, hemoptysis, hematemesis, melena, hypotension, tachycardia, dizziness.

Test all urine, stool, emesis for gross and occult blood. Monitor platelet counts daily. Administer blood components as directed. Keep patient on bed rest during bleeding episodes.

Patient Education and Health Maintenance: Teach signs and symptoms of infection and advise whom to notify. Encourage adequate nutrition to prevent emaciation from chemotherapy. Teach avoidance of constipation with increased fluid and fiber, and good perineal care. Teach bleeding precautions.

Encourage regular dental visits to detect and treat dental infections and disease.