COURSE: MEDICAL SURGICAL

NURSING II

COURSE CODE: NSC 322

TOPIC: LEUKAMIA

LECTURER: MRS CHUKWU

DATE: TUESDAY, 7TH JUNE,

2022
GROUP MEMBERS
NSC/19/1404
NSC/19/1405
NSC/19/1408
NSC/19/1409
NSC/19/1410
LEUKAEMIA
DEFINITION:

Leukaemias are disorders of blood forming tissues characterized by an uncontrolled proliferation of

white blood cells in the bone marrow replacing normal marrow elements, liver spleen, lymph nodes,
and non-hematologic organs (skin, kidney, GIT, and CNS)

Leukamia is an uncontrolled proliferation of abnormal white blood cells which leads to cellular
destruction destruction due to infilteration of the leukamia cells into the body tissue.

The common feature of the leukemias is an unregulated proliferation of leukocytes in the bone
marrow. In acute forms (or late stages of chronic forms), the proliferation of leukemic cells leaves
little room for normal cell production. There can also be a proliferation of cells in the liver and spleen
(extramedullary hematopoiesis). With acute forms, there can be infiltration of leukemic cells in other
organs, such as the meninges, lymph nodes, gums, and skin.

PATHOPHYSIOLOGY:

In leukamia is an uncontrolled proliferation of immature cells (blasts) in the bone marrow and
peripheral tissue. These immature cells suppress the proliferation of normal cells leading to
severe anaemia, thrombocytopenia (hemorrhage) and granlocytopenia (infection) due to
reduced immunity.
LEUKAEMIA

Any of the causes

Uncontrolled proliferation of white blood cells (leukocytes)

Suppression of proliferation of normal cells

Reduced immunity

Anaemia, granlocytopaenia (infection), thrombocytopaenia (haemorrhage)

TYPES:
1. Acute Myelogenous Leukaemia (AML) or acute non lymphocytic leukamia
2. Acute Lymphocytic Leukamia (ALL)
3. Chronic Myelogenous Leukamia (CML)
4,. Chronic Lymphocytic Leukamia (CLL)

The leukemias are commonly classified according to the stem cell line involved, either lymphoid
(referring to stem cells that produce lymphocytes) or myeloid (referring to stem cells that produce
nonlymphoid blood cells). They are also classified as either acute or chronic, based on the time it
takes for symptoms to evolve and the phase of cell development that is halted (i.e., with few
leukocytes differentiating beyond that phase). In acute leukemia, the onset of symptoms is abrupt,
often occurring within a few weeks. Leukocyte development is halted at the blast phase, and thus
most leukocytes are undifferentiated cells or blasts. Acute leukemia can progress rapidly, with death
occurring within weeks to months without aggressive treatment. In chronic leukemia, symptoms
evolve over a period of months to years, and the majority of leukocytes produced are mature. Chronic
leukemia progresses more slowly; the disease trajectory can extend for years

Acute Myeloid Leukemia:

Acute myeloid leukemia (AML) results from a defect in the hematopoietic stem cell that
differentiates into all myeloid cells: monocytes, granulocytes (e.g., neutrophils, basophils,
eosinophils), erythrocytes, and platelets. Any age group can be affected, although it infrequently
occurs before age 45, and the incidence rises with age, with a peak incidence at age 67 (American
Cancer Society [ACS], 2014a). AML is the most common non-lymphocytic leukemia. The prognosis
and survival rates are highly variable. Factors influencing a more positive outcome are younger age at
diagnosis, more favorable cytogenetic alterations (which are strongly associated with younger age),
and few concurrent (or mild) health problems. In contrast, individuals with significant comorbidities,
of older age, with cytogenetic features deemed to be adverse, or who are frail, are more likely to have
a poor prognosis.

Chronic Myeloid Leukemia:

Chronic myeloid leukemia (CML) arises from a mutation in the myeloid stem cell. Normal myeloid
cells continue to be produced, but there is a pathologic increase in the production of forms of blast
cells. Therefore, a wide spectrum of cell types exists within the blood, from blast forms to mature
neutrophils. Because there is an uncontrolled proliferation of cells, the marrow expands into the
cavities of long bones, such as the femur, and cells are also formed in the liver and spleen
(extramedullary hematopoiesis),

Acute Lymphocytic Leukemia:

ALL results from an uncontrolled proliferation of immature cells (lymphoblasts) derived from the
lymphoid stem cell. The cell of origin is the precursor to the B lymphocyte in approximately 75% of
ALL cases; Tlymphocyte ALL occurs in approximately 25% of cases. The BCR-ABL translocation
(see earlier CML discussion) is found in 20% of ALL blast cells. ALL is most common in young
children, with boys affected more often than girls; the peak incidence is 4 years of age. After 15 years
of age, it is relatively uncommon, until age 50 when the incidence again rises (Larson & Richard,
2016). ALL is very responsive to treatment; complete remission or response rates are approximately
85% for adults (DeAngelo, 2015). Increasing age appears to be associated with diminished survival.

Chronic Lymphocytic Leukemia:

Chronic lymphocytic leukemia (CLL) is a common malignancy of older adults, and the most
prevalent type of adult leukemia in the Western world. The average age at diagnosis is 72 years. CLL
is rarely seen in Native Americans and infrequently among persons of Asian descent. Unlike other
forms of leukemia, a strong familial predisposition exists with CLL; the disease can occur in 10% of
those with a first- or second-degree relative with the same diagnosis.

CAUSES:

1. Exposure to radiation
2. Chemical agents e.g. Benzene and alkylating chemotherapeutic agent
3. Infectious agents e.g. Virus
4. Genetic variables (familiar occurrence and down syndrome)
5. Immunodeficiency

NURSING DIAGNOSIS:

1. Ineffective tissue perfusion related to suppression of normal blood cells evidence by

pallor.
2. Pain (bone and joints) related to pressure from rapidly proliferating cells in the bone
marrow evidence by patient complain.
3. High risk for infection related to suppression.

MANAGEMENT/PHARMACOLOGY:

MEDICAL MANAGEMENT OF LEUKEMIA.

Treatment for your leukemia depends on many factors. Your doctor determines your leukemia
treatment options based on your age and overall health, the type of leukemia you have, and whether it
has spread to other parts of your body, including the central nervous system.

Common treatments used to fight leukemia include:

CHEMOTHERAPY: Chemotherapy is the major form of treatment for leukemia. This drug
treatment uses chemicals to kill leukemia cells. Depending on the type of leukemia you have, you
may receive a single drug or a combination of drugs. These drugs may come in a pill form, or they
may be injected directly into a vein.

TARGET THERAPY: Targeted drug treatments focus on specific abnormalities present within
cancer cells. By blocking these abnormalities, targeted drug treatments can cause cancer cells to die.
Your leukemia cells will be tested to see if targeted therapy may be helpful for you.

RADIATION THERAPY: Radiation therapy uses X-rays or other high-energy beams to damage
leukemia cells and stop their growth. During radiation therapy, you lie on a table while a large
machine moves around you, directing the radiation to precise points on your body.

You may receive radiation in one specific area of your body where there is a collection of leukemia
cells, or you may receive radiation over your whole body. Radiation therapy may be used to prepare
for a bone marrow transplant.

BONEMARROWTRANSPLANT: A bone marrow transplant, also called a stem cell transplant,

helps reestablish healthy stem cells by replacing unhealthy bone marrow with leukemia-free stem
cells that will regenerate healthy bone marrow. Prior to a bone marrow transplant, you receive very
high doses of chemotherapy or radiation therapy to destroy your leukemia-producing bone marrow.
Then you receive an infusion of blood-forming stem cells that help rebuild your bone marrow. You
may receive stem cells from a donor or you may be able to use your own stem cells.

IMMUNOTHERAPY: Immunotherapy uses your immune system to fight cancer. Your body's
disease-fighting immune system may not attack your cancer because the cancer cells produce proteins
that help them hide from the immune system cells. Immunotherapy works by interfering with that
process.

Medication Includes:

1. Corticosteroids
2. Antineoplastic agents e.g. Incristine
3. Xanthine-oxidase inhibitor-allupurinol
4. Daunorubicin, cytarabine and thioguamine for AML
5. Analgesics are used to allenoate headaches and joint pains
6. Antibiotics e.g. aminoglycosides for infection
7. Blood transfusions are used to maintain normal haemophobic levels and to correct
thrombocytopenia
8. Radiotherapy may also be used with medications
 9. Surgically bone marrow transplant is performed in severe cases.

NURSING MANAGEMENT:

1. Systematically assess for evidence of infection, severe inflammation and pain.

2. Monitor vitals especially temperature closely and report evaluation
3. Maintain a positive environment as indicated until infection subsides
4. Maintain integrity of the skin and mucous membrane
5. Encourage rest to conserve energy
6. Nurse patient in a calm environment to avoid irritation of the nerves and to reduce
headache
7. Promote positive coping mechanism to help the client and family deal with stressors
related to the disease and its treatment
8. Institute measures to prevent bleeding and monitor for bleeding
9. Provide pain relief as needed as prescribed
10. Meticulous skin care especially oral hygiene and perianal area
11. Encourage adequate protein and calorie intake and fluid intake to maintain nutrition and to
prevent uric acid formation
12. Avoid urinary catheterization if possible
13. Provide patient with adequate information about the condition, the management of
medication to alley anxiety.

CLINICAL MANIFESTATIONS:

1. Anemia
2. Pallor infection
3. Fatigue
4. Weight loss
5. Anorexia
6. Bleeding tendencies
7. Bone and joint pain
8. Headache
9. Confusion
10. Fever
11. Splenomegaly
12. Hepatomegaly due to tissue invasion
13. Vomiting due to henigeal irritation.

NURSING PROCESS
Assessment:

Although the clinical picture varies with the type of leukemia as well as with the treatment
implemented, the health history may reveal a range of subtle symptoms reported by the patient before
the problem is detectable on physical examination. If the patient is hospitalized, assessments should
be performed daily, or more frequently as warranted. Because the physical findings may be subtle
initially, a thorough, systematic assessment incorporating all body systems is essential. For example,
a dry cough, mild dyspnea, and diminished breath sounds may indicate a pulmonary infection.
However, the infection may not be seen initially on the chest x-ray; the absence of neutrophils delays
the inflammatory response against the pulmonary infection, thus delaying radiographic changes.
When serial assessments are performed, current findings are compared with previous findings to
evaluate improvement or worsening. Specific body system assessments are delineated in the
neutropenic and bleeding precautions. The nurse also must closely monitor the results of laboratory
studies, including tracking the leukocyte count, ANC, hematocrit, platelet, creatinine and electrolyte
levels, and coagulation and hepatic function tests. Culture results need to be reported immediately so
that appropriate antimicrobial therapy can begin or be modified.

DIAGNOSIS

NURSING DIAGNOSIS

Based on the assessment data, major nursing diagnoses may include: Risk for infection, bleeding, or
both Impaired oral mucous membranes due to changes in epithelial lining of the GI tract from
chemotherapy or prolonged use of antimicrobial medications Imbalanced nutrition: less than body
requirements related to hypermetabolic state, anorexia, mucositis, pain, and nausea Acute pain and
discomfort related to mucositis, leukocyte infiltration of systemic tissues, fever, and infection Fatigue
and activity intolerance related to anemia, infection, inadequate nutrition, and deconditioning Risk for
imbalanced fluid volume related to renal dysfunction, diarrhea, bleeding, infection, increased
metabolic rate, hypoproteinemia, and need for multiple intravenous medications and blood products
Self-care deficits (bathing, dressing, toileting) due to fatigue and malaise Anxiety and grieving due to
uncertainty about future, anticipatory loss, and altered role functioning Risk for spiritual distress
Deficient knowledge about disease process, treatment, complication management, and self-care
measures

COLLABORATIVE/POTENTIALCOMPLICATIONS

Potential complications may include the following Infection Bleeding/DIC Renal dysfunction Tumor
lysis syndrome Planning and Goals. The major goals for the patient may include absence of
complications and pain, attainment and maintenance of adequate nutrition, activity tolerance, ability
to provide self-care and to cope with the diagnosis and prognosis, positive body image, and an
understanding of the disease process and its treatment.

NURSING INTERVENTIONS:

PREVENTING OR MANAGING MANAGING MUCOSITIS:

Although emphasis is placed on the oral mucosa, the entire GI mucosa can be altered, not only by the
effects of chemotherapy but also from prolonged administration of antibiotics

NUTRITIONAL INTAKE:

The disease process can increase the patient’s metabolic rate and nutritional requirements. Nutritional
intake is often reduced because of pain and discomfort associated with stomatitis. Encouraging or
providing mouth care before and after meals and administering analgesic agents before eating can
help increase intake. If oral anesthetic agents are used, the patient must be warned to chew with
extreme care to avoid inadvertently biting the tongue or buccal mucosa. Nausea should not interfere
with nutritional intake, because appropriate antiemetic therapy is highly effective. However, nausea
can result from antimicrobial therapy, so some antiemetic therapy may still be required after the
chemotherapy has been completed. Small, frequent feedings of foods that are soft in texture and
moderate in temperature may be better tolerated. Low-microbial diets may be prescribed (avoiding
uncooked fruits or vegetables and those without a peelable skin), although there is little evidence to
support this intervention (Foster, 2014). Nutritional supplements are frequently used. Daily body
weight (as well as intake and output measurements) is useful in monitoring fluid status. Both calorie
counts and more formal nutritional assessments are often useful. Parenteral nutrition may be required
to maintain adequate nutrition.

EASING PAIN AND DISCOMFORT

Recurrent fevers are common in acute leukemia; at times, they are accompanied by shaking chills
(rigors), which can be severe. Myalgias and arthralgias can result. Acetaminophen (Tylenol) is
typically given to decrease fever, but it also increases diaphoresis. Sponging with cool water may be
useful, but cold water or ice packs should be avoided because the heat cannot dissipate from
constricted blood vessels. Bedclothes need frequent changing as well. Gentle back and shoulder
massage may provide comfort. Mucositis can also cause significant discomfort. In addition to oral
hygiene practices, patient-controlled analgesia can be effective in controlling the pain. With the
exception of severe mucositis, less pain is associated with acute leukemia than with many other forms
of cancer. However, the amount of psychological suffering that the patient endures can be immense.
Patients often benefit from active listening and possible referral for professional counseling.

DECREASING FATIGUE AND ACTIVITY INTOLERANCE

Fatigue is a common and oppressive symptom. Nursing interventions should focus on assisting the
patient to establish a balance between activity and rest. Patients with acute leukemia need to maintain
some physical activity and exercise to prevent the deconditioning that results from inactivity. The use
of a high-efficiency particulate air (HEPA) filter mask can permit the patient to ambulate outside the
room despite severe neutropenia. Stationary bicycles may also be set up in the room; however, many
patients lack the motivation or stamina to use them. At a minimum, patients should be encouraged to
sit up in a chair while awake rather than staying in bed; even this simple activity can improve the
patient’s tidal volume and enhance circulation. Physical therapy can also be beneficial. Patients with
acute leukemia may require hospitalization for extensive nursing care (either during induction or
consolidation therapy or during resultant complications); sleep deprivation frequently results. Nurses
need to implement creative strategies that permit uninterrupted sleep for at least a few hours while
still administering necessary medications on schedule

MAINTAINING FLUID AND ELECTROLYTE BALANCE

Febrile episodes, bleeding, and inadequate or overly aggressive fluid replacement can alter the
patient’s fluid status. Similarly, persistent diarrhea, vomiting, and long-term use of certain
antimicrobial agents can cause significant deficits in electrolytes. Intake and output need to be
measured accurately, and daily weights should also be monitored. The patient should be assessed for
signs of dehydration as well as fluid overload, with particular attention to pulmonary status and the
development of dependent edema. Laboratory test results, particularly electrolytes, blood urea
nitrogen, creatinine, and hematocrit, should be monitored and compared with previous results.
Replacement of electrolytes, particularly potassium and magnesium, is commonly required. Patients
receiving amphotericin or certain antibiotics are at increased risk for electrolyte depletion.

IMPROVING SELF-CARE: BATHING, DRESSING, AND TOILETING

Because hygiene measures are so important in this patient population, they must be performed by the
nurse when the patient cannot do so. However, the patient should be encouraged to do as much as
possible to preserve mobility and function as well as self-esteem. Patients may have negative feelings
because they can no longer care for themselves. Empathetic listening is helpful, as is realistic
reassurance that these deficits are temporary. As the patient recovers, the nurse assists him or her to
resume more self-care. Patients are usually discharged from the hospital with a vascular access device
(e.g., Hickman catheter, peripherally inserted central catheter [PICC]), and coordination with
appropriate home care services is needed for catheter management.

MANAGING ANXIETY AND GRIEF

Being diagnosed with acute leukemia can be extremely frightening. In many instances, the need to
begin treatment is emergent, and the patient has little time to process the fact that he or she has the
illness before making decisions about therapy. Providing emotional support and discussing the
uncertain future are crucial. The nurse also needs to assess how much information the patient wants
to have regarding the illness, its treatment, and potential complications. This desire should be
reassessed at intervals, because needs and interest in information change throughout the course of the
disease and treatment. Priorities must be identified so that procedures, assessments, and self-care
expectations are adequately explained even to those who do not wish extensive information. Many
patients exhibit depressive symptoms and begin to grieve fortheir losses, such as normal family
functioning, professional roles and responsibilities, and social roles, as well as physical functioning.
The nurse can assist the patient to identify the source of the grief and encourage him or her to allow
time to adjust to the major life changes produced by the illness. Role restructuring, in both family and
professional life, may be required. Again, when possible, encouraging the patient to identify options
and to take time making important decisions is helpful.

Nursing Interventions Rationale

Place in a private room. Limit visitors as indicated.
To protect the patient from potential sources of
Prohibit live plants or flowers. Restrict fresh fruits
pathogens
and or infection. Bone marrow suppression,
make sure they are properly washed or neutropenia, peeled. and chemotherapy places the patient at
Coordinate patient care so that leukemic patienthigh
doesn’t
risk for infection.
come in contact with staff who also care for patients with
infections or infectious diseases.

Require good hand washing protocol for all personnel

Prevents cross-contamination and reduces risk of
and visitors. infection.
Closely monitor temperature. Note correlation Although
between fever may accompany some forms of
temperature elevations and chemotherapy treatments.
chemotherapy, progressive hyperthermia occurs in
Observe for fever associated somewith types of infections, and fever (unrelated to drugs
tachycardia, hypotension subtle mental changes. or blood products) occurs in most leukemia patients.
Septicemia may occur without fever.
Prevent chilling. Force fluids, administer tepidHelps
spongereduce fever, which contributes to fluid
bath. imbalance, discomfort, and CNS complications.

Encourage frequent turning and deep breathing. Prevents stasis of respiratory secretions, reducing risk
of atelectasis or pneumonia
Auscultate breath sounds, noting crackles, Early rhonchi.
intervention is essential to prevent sepsis
Inspect secretions for changes in characteristics:
immuno-suppressed person.
increased sputum production or change in sputum color.
Observe urine for signs of infection: cloudy, foul-
smelling, or presence of urgency or burning with voids.

Handle patient gently. Keep linens dry and wrinkle-free.

Prevents sheet burn and skin excoriation

Inspect skin for tender, erythematous areas; Mayopen

indicate local infection. Open wounds may not
wounds. Cleanse skin with antibacterial solutions.produce pus because of insufficient number of
granulocytes.
Inspect oral mucous membranes. Provide good The oral cavity is an excellent medium for growth of
hygiene. Use a soft toothbrush, sponge, or swabs
organisms
for and is susceptible to ulceration and bleeding
frequent mouth care.

Avoid using indwelling urinary catheters and giving

These
I.M.
can provide an avenue for infection
injections.
Provide thorough skin care by keeping the patient’s
Additional
skin measures to avoid infection.
and perianal area clean, apply mild lotion or creams to
keep the skin from drying or cracking. Thoroughly clean
skin before all invasive skin procedures

Change IV tubing according to your facility’s policy.

IV sites
Use can harbor infection. Additional measure to
strict sterile technique and a metal scalp veinavoid
needles
infection.
(metal butterfly needle) when starting IV. If the patient
receives total parenteral nutrition, give scrupulous
subclavian catheter care.
Promote good perianal hygiene. Examine perianal Promotes
area at cleanliness, reducing risk of perianal abscess;
least daily during acute illness. Provide sitz baths,
enhances
using circulation and healing. Perianal abscess can
Betadine or Hibiclens if indicated. Avoidcontribute rectal to septicemia and death in immune
temperatures, use of suppositories. compromised patients.

Coordinate procedures and tests to allow Conserves

for energy for healing, cellular regeneration.
uninterrupted rest periods.
Limit invasive procedures (venipuncture and injections)
Break in skin could provide an entry for pathogenic or
as possible. potentially lethal organisms. Use of central venous lines
(tunneled catheter or implanted port) can effectively
reduce need for frequent invasive procedures and risk
of infection. 

REFERENCES

1. Brunners and Suddarths Medical surgical nursing (14th Edition)

2. Explicit medical surgical nursing
3. Nurses lab.
4. Synopsis on medical surgical nursing