ACUTE LYMPHOBLASTIC LEUKEMIA

1. GENERAL OBSERVATION

Acute Lymphoblastic Leukemia is a kind of cancer that progresses rapidly. The

bone marrow produces too many immature lymphocytes which affect red blood
cells, white blood cells, and platelets, and are unable to fight infections very well.

Patients with Acute Lymphoblastic Leukemia have to many stem cells that
became lymphoblast specifically B-lymphocytes or T-lymphocytes. There will be
no more adequate room for the healthy WBC, RBC and platelets because many of
the lymphocytes are not acting as a normal cells. These Cancer cells may
increase in the bone marrow and the blood, and this may go on thourgh
infections, anemia and easy bleeding.

2. RISK GROUP FOR CHILDREN

Children is the most common type of cancer in children. Kids below are more
prone to Acute Lymphoblastic Leukemia:
 Being exposed to xrays before birth.
 Being exposed to radiationx
 Patients having genetic complications for example:
Down Syndrome (Trisomy 21)
Bloom Syndrome
 Having changes of in the chromosomes and genes
 Constitutional changes
On the other hand, there are different risk groups for children that are classified
through the different features that they manifest.
 Standard-Risk Acute Lymphoblastic Leukemia:

 they are between age 1 and 10

 they have less than 50,000 white blood cells per cubic millimetre
(mm3) of blood when they are diagnosed
 No blasts in the CSF (CNS 1) or less than 5 blasts in CSF (CNS 2)
 no testicular leukemia
 no unfavorable cytogenetic features
 no steroids were given before diagnosis of leukemia
 a good response to the first phase of chemotherapy (induction),
as measured by a bone marrow test on day 29 with MRD.

 High-Risk Acute Lymphoblastic Leukemia:

 less than age one or older than ten years of age

 more than 50,000 white blood cells/mm3 of blood when they are
diagnosed
 More than 5 leukemic cells in the CSF (CNS 3)
  leukemia cells with chromosome changes that are more difficult
to treat
 testicular involvement
 steroids given before diagnosis of leukemia.

 Very High-Risk Acute Lymphoblastic Leukemia:

 Children with certain chromosome changes inside their leukemia

cells that make it harder to treat. They may require other special
types of medication.

3. SIGNS AND SYMPTOMS

The signs and symptoms of Acute Lymphoblastic Leukemia are as follows:
 High fever;
 Thrombocytopenia or low blood platelet count;
 Abnormal bleeding such as nosebleeds and gingival bleeding;
 Easy bruising even after minor trauma;
 Dyspnea or shortness of breath;
 Anemia due to decrease in production of red blood cells
 Fatigue that is more frequently than normal;
 Tachycardia or faster heartbeats than normal;
 Bone pain;
 Frequent infections;
 Lumps due to swollen lymph nodes in common areas such as neck,
underarm, abdomen, or even groin;
 Petechiae or dark red spots under the skin
 Pain or feeling fullness below the ribs; and
 Loss of appetite.

4. TREATMENT
The treatment of chillhood ALL have three phases:
a) Remission Induction: The goal of this phase is to kill the leukemia in the
cells in the blood and bone marrow. This puts the leukemia in remission.
b) Consolidation/Intensification: After the remission of the leukemia this
second phase the goal is to kill all the leukemia cells that remain in the
body and may cause a relapse.
c) Maintenance: The goal of this phase is to kill the any leukemia that may
regrow and cause a relapse.

There are 4 types of therapeutic management the patient can undergo for
treatment; the 4 standard treatment used are:

a) Chemotherapy is a therapeutic treatment that uses drugs to either stop the

growth of the cancer cells or killing/stopping the cancer cells and keeping
them from dividing. There are two route that chemotherapy can be
administered. The first one is through the mouth or through Intravenous or
Intramuscular, For the drug to enter to the blood stream and reach the
cancer cells in the body. The second one is directly into the Cerebrospinal
 fluid (Intrathecal), an specific organ or a body cavity such as the abdomen.
Intrathecal may use to treat ALL that spread, may spread through out the
brain and spinal cord.
Combination Chemotherapy- A chemotherapy that usage of two or more
anticancer drug.

b) Radiation Therapy is the usage of high-energy x-rays or other types of

radiation to reduce the cancer cells or stopping them to grow. There are two
types :
a. External radiation therapy – A machine that uses radiation outside
the body to give the radiation toward the cancer.
b. Internal radiation therapy – It uses a sealed needles, seed, wires or
catheter, all a radioactive substances, that will be place directly into
the cancer.
Radiation Therapy may also be use to prepare the bone marrow for stem
cell transplant.

c) Targeted Therapy is a kind of therapeutic treatment that uses drugs or

other substances to Identify and attack specific cancer cells without
destroying the normal cells. There are three different types of Targeted
Therapy:
a. Tyrosine Kinase Inhibitors- are types of drug that block the
enzyme, Tyrosine kinase, which the cause of increase in production
of white blood cells or blast in the body.
b. Monoclonal Antibody- Is a type of cancer treatment with the use of
antibodies that have been studied in the lab. These antibodies are
made for attacking directly to specific cells and kills them.
c. Proteasome Inhibitor- Is a type of therapy that removes the
proteins in the cancer cell that may cause the cancer cell to die.

5. NURSING CONSIDERATIONS

 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.
 Avoid invasive procedures and trauma to skin or mucous membrane to
prevent entry of microorganisms.
 Encourage and assist patient with personal hygiene, bathing, and oral
care.
 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.
 Keep patient on bed rest during bleeding episodes.
 Encourage adequate nutrition to prevent emaciation from chemotherapy.

6. THE CONNECTION OF BLOOD TRANSFUSION WITH ACUTE

LYMPHOBLASTIC LEUKEMIA:
Blood transfusion plays a very important role to children diagnosed with
Acute Lymphoblastic Leukemia. They need periodic blood transfusions because of
the following reasons:
 The disease process itself can sometimes interfere with the normal
production of red cells, white cells and platelets in the bone marrow.
 Many chemotherapy drugs can temporarily impair blood cell
production in the marrow and depress immune system functions.
 Stem cell transplantation patients receive high doses of chemotherapy,
which depletes stores of normal blood cells.

In fact, in Thailand, patients with this type of leukemia are required to

undergo blood transfusion for one year.