Managing the Client with

Leukemia

MODULE DESCRIPTION
This module contains the necessary information regarding the different types of leukemia
and their origins. Also contained in the module are the treatment modalities used in treating
leukemia as well as their complications and the nursing interventions the nurse should implement
if encountered with these problems.
LEARNING OUTCOME
At the end of this module, the student will have a clear understanding on the different
types of leukemia as well as the treatment modalities. More importantly, the student will have
the competency of dealing with the client suffering from leukemia.

PRE-TEST
1. A type of leukemia that results from the defect on the differentiation of hematopoietic
stem cells.
a. Chronic myeloid leukemia
b. Acute lymphocytic leukemia
c. Acute myeloid leukemia
d. Chronic lymphocytic leukemia
2. Acute lymphocytic leukemia can cause meningismus due_____.
a. Myelodepression
b. Angioedema
c. Cerebral edema
d. Intracranial hypertension
3. A client with AML is about to be given with carboplatin IV. Which of the following
medications should the nurse anticipate giving the client prior to administration of
carboplatin?
a. Palonosetron IV + dexamethasone IV
b. Metoclopramide IV + haloperidol IV
c. Erythropoietin alfa SQ
d. Omeprazole IV + granisetron IV
4. A client underwent radiotherapy due to CML. His absolute neutrophil count was
2000/cu.mm. Which of the following should the nurse anticipate to administer?
a. Erythropoietin alfa SQ
b. Oprelvekin
c. Filgrastim
 d. Pegfilgrastim
5. A client was seen in the clinic with sudden weight loss, several lymphadenopathies and
easing bruising. The doctor suspect of leukemia. Which of the following diagnostic tools
confirms this diagnosis?
a. CT scan with contrast
b. Lymph node aspiration
c. Bone marrow aspiration
d. MRI with gadolinium-dye enhancement

MODULE CONTENT

Leukemia
 Neoplastic proliferation of one particular type of white blood cell.
 It is the unregulated multiplication of leukocytes in the bone marrow.
 Causes:
o Unknown
o Risks:
 Genetic influences
 Viral infection
 Exposure to chemicals or radiation
 It is commonly classified as:
o Lymphoid or myeloid
o Acute or chronic

TYPES OF LEUKEMIAS
1. Acute myeloid leukemia
a. Results from a defect in the hematopoietic stem cell that differentiates into all
myeloid cells (monocytes, granulocytes, RBCs and platelets).
b. Affects all age group, but incidence rises with age.
c. Manifestations:
i. Fever
ii. Frequent infections
iii. Bleeding tendencies
iv. Hepatomegaly or splenomegaly
v. Gingival hyperplasia
vi. Bone pain
d. Diagnostics
i. CBC with differential
ii. Bone marrow biopsy
1. Shows excess immature blastic cells
e. Complications:
i. Bleeding tendencies like petechiae and ecchymosis
ii. Hemorrhage
iii. Fever
 iv. Infections
2. Chronic Myeloid Leukemia
a. Arises from the mutation of the myeloid cells
b. A wide spectrum of cell types exist from blast cells to mature WBCs.
c. The malignant cells expands in the bone marrow, especially the femurs. Also,
extramedullary hematopoiesis may exist in the spleen and the liver.
d. Caused by missing Philadelphia chromosome in the chromosome 22 and is
translocated to chromosome 9.
e. The specific location changes are the BCR gene of chromosome 22 and the ABL
gene of chromosome 9.
f. Manifestations:
i. Usually asymptomatic
ii. Extreme leukocytosis in CBC
iii. Vague respiratory symptom like SOB and neurologic symptom like
confusion due to leukostasis
iv. Splenomegaly or hepatomegaly
v. Malaise, anorexia and weight loss
g. Diagnostics:
i. CBC with differential panel
ii. Bone marrow biopsy
iii. Imaging procedures
1. UTZ
2. CT scan
3. Acute Lymphocytic Leukemia
a. Results from an uncontrolled proliferation of immature cells of the lymphoid stem
cells
b. Common in young children
c. Manifestations:
i. Pancytopenia
ii. Tenderness over the spleen or liver
iii. Meningismus
1. Caused by leukemic infiltration of the CNS
2. Vomiting, headache, nausea, alteration of LOC
d. Diagnostics:
i. CBC
ii. Bone marrow biopsy
iii. Imaging procedures
iv. CSF analysis
4. Chronic Lymphocytic Leukemia
a. Common malignancy among adults
b. Caused by the ability of B-lymphocytes (sometimes T-lymphocytes, but rare) to
escape cell death of apoptosis causing them to accumulate
c. Manifestations:
i. Pulmonary and cerebral symptoms and complications due to leukostasis
ii. Lymphadenopathies
iii. Splenomegaly and hepatomegaly
 iv. Anemia and thrombocytopenia
v. Fever
vi. Drenching night sweats
vii. Unintentional weight loss
viii. Anergia
d. Complications:
i. Autoimmune hemolytic anemia
ii. Idiopathic thrombocytopenic purpura
iii. Recurrent and pronounced infections

TREATMENT MODALITIES FOR LEUKEMIA

CHEMOTHERAPY
 The administration of pharmacologic agent that arrests cell division in various stages by
inhibiting different cellular mechanisms that are involved in cellular division and
multiplication.
 Antineoplastic drugs used in leukemia is usually used to suppress the bone marrow
activity and reduced leukemic complications.
 Also used to manage pain related to congestion of leukemic cells in the bones, spleen or
liver.
 Intrathecal administration of antineoplastic drugs (eg. Methotrexate) is used in ALL and
CLL to control cerebral complications of the said leukemia.
 Usually used in combination or called “cocktails” to target cells in different stages and
increase the likelihood of killing more cells than using monotherapy.
 Usually done in cycles and a maintenance phase is set in between cycles or sessions.

RADIOTHERAPY
 Usually done to suppress the bone marrow in preparation for bone marrow transplant
 Targeted radiotherapy (also known as stereotactic gamma-ray knife) is used to shrink
metastatic tumors (leukemic infiltrations) deep into the brain and other organs.
 Like in chemotherapy, it is usually done in sessions, with interval between sessions to let
the body recover from the effects of radiation.

MONOCLONAL ANTIBODY THERAPY (IMMUNOTHERAPY)

 The use of laboratory-synthetized antibodies that target specific antigen (usually a cancer
antigen) and induce a wide-range of cellular response from enhancing the healthy
immune cells to eliminate the cancer cell, use for tagging to augment the effects of
antineoplastic drugs or induce cell death.
 Example: rituximab and alemtuzimab used for CLL.

ADJUNCTIVE THERAPY
 Colony-stimulating factors
o Are glycoproteins that increase the production of blood cells that enhance cellular
immunity.
 o Usually described ad granulocyte colony-stimulating factor (G-CSF) or
macrophage and granulocyte colony-stimulating factors (GM-CSF)
o Used also to stimulate the bone marrow to increase RBC production.
o Used to reduced neutropenia and decrease the incidence of infection or to treat
chemotherapy- or radiation- therapy induced anemia
o No evidence that it may stimulate the proliferation of malignant cells.
o Examples:
 Sargramostim (Leukine): GM-CSF
 Filgrastim (Neupogen): G-CSF
 Pegfilgrastim (Neulasta)
 Epoietin alfa (Epogen): for RBC production
 Cell-stimulating medications
o Are interleukins (biologic response modifiers) that has a wide range of cellular
proliferating effect in the body.
o Oprelvekin (Neumega) is used to stimulate the production of megakaryocytes thus
increasing platelet production.
 Pain management
o One of the most dreaded effect of cancer and its treatment is pain.
o Leukemic infiltration and metastasis and the subsequent compression of nearby
nerves and vessels causes excruciating pain.
o The use of narcotics or opioid analgesics is the golden standard of cancer pain
control.
o Additionally the use of minor tranquilizers such as midazolam or clonazepam
potentiates the pain-killing effects of narcotics.
o Combing short and long-acting narcotics have been a major part in cancer pain
management. Example is the combination of IV morphine followed by an
extended- or sustained release oral narcotic.
o The use of patient-controlled analgesia has given the client more liberty on the
timely dosing of pain-killers making pain management, independent from the
healthcare provider.

HEMATOPOITEIC STEM-CELL TRANSPLANTATION (HSCT)

 The general term used to describe procedures of transplanting blood stem cells which
includes bone marrow transplant (BMT) and peripheral blood stem cell transplant
(PBSCT).
 Hematopoietic stem-cell transplantation is a treatment modality wherein multipotent
hematopoietic stem cells (HSCs) from a donor bone marrow is transplanted via IV route
to a recipient host.
 Used to treat a variety of hematologic disorders including oncologic disorder of the bone
marrow and blood.

TYPES OF GRAFTS:
 Grafts are the source of the stem-cells.
o Autologous- stem cells harvested from the patient’s own body.
o Allogenic- cells coming from a donor
 Types:
Bone marrow stem cells- hematopoietic cells aspirated directly from the
donor’s bone marrow.
 Umbilical stem cells
 Amniotic fluid
 Embryonic stem cells- controversial source of stem cells as these cells are
harvested from excess fertilized eggs from in-vitro fertilization
laboratories
 Fetal stem cells- controversial source as these cells are harvested from
aborted fetuses.
 Peripheral blood stem cells- harvested from the donor, done peripherally
and is processed through apharesis. The most common source of HSCs.
o Synegeic- HSCs harvested from the patient’s identical twin.

PROCESS OF TH DETERMING COMPATIBILITY AND VIABLITY OF DONOR CELLS

1. The ABO and Rh types of the donor and the recipient is matched.
2. Human Leukocyte Antigen (HLA) is matched.
3. The donor undergoes screening of common blood-borne diseases.
4. Once a match is found, the client undergoes radiotherapy and/or chemotherapy to deplete
the bone marrow and is temporarily placed under strict protective isolation
5. Pre-medication with anti-rejection drugs and corticosteroid is given prior to the infusion
of the HSCT.
6. The HSCT may be successful on the first infusion, however, there are some instances
that it may fail and the process should be repeated. If the HSCT failed, the patient is at a
greater risks of severe myelosuppresion and should be kept on protective isolation and
transfusion of necessary blood products like RBCs and platelets should be done
repeatedly.

GRAFT-VERSUS-HOST DISEASE (GVHD)

 One of the most life-threatening complication of BMT or PBSCT is GVHD.
 This is when the HSC has established in the bone marrow and starts functioning.
However, the produced immune cells by the new bone marrow attacks the client’s own
cells causing a variety of signs and symptoms, which ultimately cause the destruction of
vital organs like the liver, kidneys, heart, lungs and brain
 It usually occurs in HSCT using allogenic sources, even with the most stringent screening
and tissue cross-matching and typing. This is so because no two human being is
genetically identical (except for monozygotic identical twins) and these slight differences
have a huge impact on the stimulation of the immune cells produced by the donor bone
marrow.
 Signs and symptoms:
o Abdominal pain or cramps
o Nausea and vomiting
o Diarrhea
o Jaundice and elevation of liver enzymes
o Tea-colored or blood streak urine and elevation of renal proteins
 o Skin manifestations (itching and redness)
 Management:
o Acute:
 High-dose corticosteroids
 Sirolimus
 Tacrolimus
 Azathioprine
 Methothrexate
o Maintenance:
 Low-dose steroids
 Other anti-rejection drugs usually given in low-doses

NURSING MANAGEMENT OF THE CLIENT WITH LEUKEMIA

 As with all the management of cancers, nursing plans, goals and interventions are
directed towards the ill-effects of the cancer itself and the treatment used.

Problem
Extreme fatigue
 Nutrition depletion from nausea,
vomiting and diarrhea; competition
with the rapidly dividing cancer cells;
anemia; effects of treatment
Infection/Superinfection
 The number 1 cause of cancer-related
deaths.
 Due to direct effect of the leukemic
process (immature WBCs)
immunosuppression from
chemotherapy/radiation therapy
Management
 Provide adequate rest periods
 Plan client care
 Provide nutritional support
 Strict observance and implementation
of aseptic technique.
 Put the client in a positive-pressure
room
or  Strict hand hygiene when dealing with
the client. Patient should have his own
supplies and utensils. Dedicated
equipment such as
sphygmomanometer, thermometer,
etc.
 Limit people inside the room
(including family, nurses and other
hospital staff)
 Change the beddings and the IV
tubing q24H.
 Educate the client about DBCE to
prevent postural pneumonia
 Refrain from giving the client fresh
fruits, flowers or potted plants.
 Bathe moist warm areas of the body
such as the groin and the armpits
 Avoid raw and undercooked foods.
 Wash fruits and vegetables thoroughly

Neutropenia
 Is the decrease in the number of
neutrophils in the body.
 Neutrophils are the body’s first
defense against infection.
 The lowest point of neutrophil count is
called nadir
 Assess through the use of the absolute
neutrophil count (ANC)
 Normal ANC: 2500-8000 cell/cu.mm

Thromboembolic events
 Usually in the form of DVT
 Causes:
o Prolonged bed rest or
immobility
o Use of central lines
o Compression of vessels by
tumors
o Metastatic cells usually coat
themselves with blood clots to
evade immune response.
o Some cancer upregulates the
body’s clotting cascade
o Chemotherapy drugs
Thrombocytopenia
 Direct cause of cancer
 Caused by radiotherapy
chemotherapy
using warm, running water.
 Give the client fresh water. Water
standing at the table for more than 15
minutes is considered stale and may
have microbes in it. If possible,
provide distilled, bottled water.
 Monitor client’s temperature.
 Prophylactic antibiotics, if indicated.
 Implement neutropenic
(protective/positive pressure)
isolation.
 Observe steps as mentioned in
preventing infection/superinfection.
 Administer G-CSF (filgrastim)
Neupogen as ordered.
 Monitor VS q4H
 Strict hand hygiene
 If possible, refrain from doing any
invasive procedures.
 If indicated, avoid or remove IFCs and
NGTs.
 Limit the use of acetaminophen for
fever control.
 Monitor ANC closely
 Passive range of motion exercises
 Pneumatic compression device
 Ensure hydration
 Decompression of vessels or
embolectomy
 Assess for any overt or covert signs
and symptoms of bleeding:
or o Changes in LOC
o Conjunctival hemorrhage
o Petechiae, ecchymosis or
 purpura
o Bleeding in the rectum, ear,
nose
o Melena, hematemesis or
hematochizia
 Transfuse platelet concentrate or
platelet apharesis as indicated
 Administer oprelvekin (Neumega)
 Institute bleeding precautions:
o Avoid invasive procedures like
rectal examination IM
injection
o Avoid the use of razors or
manual shavers. Patient can
use electric razor
 Assess platelet counts
Anemia  Provide rest
 Direct cause of leukemia  Transfuse packed RBC that is
 Cause by chemotherapy or radiation screened for many blood-borne
therapy diseases, including cytomegalovirus
 Ensure that the blood product is
leukoreduced.
 Institute routine blood transfusion
precautions and procedure.
 Transfuse blood product no more than
4 hours.
 May administer erythropoietin alfa as
prescribed.
Nausea and Vomiting  Give antiemetics prior to
 Caused by emetogenic administration of emetogenic
chemotherapeutic drugs esp. those that chemotherapy drugs or start of
are platinum-based antineoplastics. radiation therapy
 Can also be caused by radiotherapy o Serotonin receptor blockers:
 Ondansetron
 Granisetron
o Phenothiazine
o Neukinin inhibitor
 Netupitant
 Antiemetics are usually combined
with low-dose dexamethasone to
potentiate their anti-emetic effects.
 For intractable N/V
o Tetrahydrocannabinol
(Marinol) or haloperidol
(Haldol)
  Complementary approach
o Aromatherapy
o Acupuncture
o Behavioral therapy
Cachexia (wasting syndrome; consumption)  Small frequent feeding
 Depletion of nutrients by the rapidly-  Appetite stimulants:
dividing cells o Buclizine
 Caused by chemotherapy/radiation o Dronabinol
therapy  Oral care to alleviate stomatitis
o Stomatitis/mucositis  Antiemetics
o N/V  Hyperalimentation
o Diarrhea o Enteral feeding
o Anorexia o TPN
 Psychological effect of cancer  Counselling
diagnosis
Pain  Administer opioids as ordered
 Can be psychological in nature due to  Opioid analgesics are the gold
anxiety standard in cancer pain management.
 Direct tumor involvement  No ceiling on the doses for a cancer
 Result of treatment such as mucositis client. It is client dependent
 Peripheral neuropathy due to  Usually given in combination of other
treatment medications such as steroids,
anxiolytics
 Given via patient-controlled analgesia
 For intractable pain:
o Propofol
o Ketamine
 Refer to pain specialists.
 Teach client on non-pharmacological
pain interventions such as but not
limited to:
o Biofeedback
o Meditation
o Behavioral therapy
o Acupuncture and hypnosis
o TENS
Psychosocial difficulties  Provide psychological support
 Body image alterations  Educate the client about the different
 Psychological crisis due to diagnosis effects of treatment such as hair loss
and treatment implications and weight loss and the interventions
 Family and caregiver stress that may be taken to address these
 Palliative and end-of-life care issues effects.
 Social isolation  Coordinate the care of the client and
his family with the hospital’s social
 work department, counselor and
psychiatrist.
 Assess the family members’ ability to
cope with stress of caring the client.
Refer them to counselor if necessary.
 Include options regarding the transfer
of the severely-ill client to a skilled
long-term facility.
 Refer to pastoral care, if applicable.
 Provide means of communication with
family and the client especially when
they are in protective isolation.
o Hospital’s intercom
o Internet messaging
 Educate the client with regarding
advance directives.

POST-TEST
1. You are caring for a client with terminal stage AML with infiltration of the spleen and
secondary tumor growth in the femoral structures. He is in patient-controlled analgesia
with the following settings: continuous infusion of morphine sulfate at 1mg per hour, an
IV bolus of 0.5mg every 4 hours and a patient-controlled IV bolus of 0.5mg, maximum of
8 boluses in 24 hours. The infusion was started at 11pm. At around 8am the following
day, the client has already consumed the 8 patient-controlled IV boluses and has been
complaining of severe pain in the femur he graded as 10/10. Which of the following
actions should the nurse do?
a. Tell the client that he has consumed the 8 IV boluses he can manually administer
and wait for the next cycle at 11pm today.
b. Tell the client that the pain is all in his brain, as the PCA pump continuously
infuses 1mg of morphine every hour.
c. Ask the doctor if he can adjust or increase the number of IV boluses the client can
administer manually
d. Give an IV bolus of NSS telling the client it is morphine.
2. The client with ALL was admitted in the hospital. His ANC is at 2010/cu.mm. Which of
the following should the nurse implement? Select all that apply.
a. Strict observance of aseptic technique.
b. Put a vase of fresh flower inside the client’s room
c. Encourage her relatives to visit him
d. Put the client in a positive-pressure room
e. Monitor client’s VS especially her temperature
f. Share the equipment used for her with other clients in the floor.
3. You are about to admit a 34 year old male client with CML, however, the floor has no
private room available. Which of the following client can the nurse cohort the CML
client?
a. A 13 year old female client with viral conjunctivitis
 b. A 30 year-old male with infected scabies
c. A 29 year old male with thalassemia major on blood transfusion
d. A 31 year old male with suspected fentanyl abuse on four-point restraint 1 hour
ago
4. A client with AML has received PBSCT a few days ago. While having your morning
hand-off report, she told you that she noticed a bloody streak on her urine this morning
and had been experiencing crampy abdominal pain more on the lower back and the RUQ.
Which of the following should the nurse suspect?
a. GVHD
b. Recurrence of the AML
c. Cholelithiasis and nephrolithiasis
d. Splenomegaly
5. A client who was diagnosed with ALL several months ago have been admitted to the
hospital due to cerebral infiltration of leukemic cells and was not able to communicate
and lethargic since then. Upon reading her chart, you noticed that she has a written
advance directive indicating that should she become incapable of deciding for herself, she
does not want any form of enteral feeding. However, her husband has been insisting to
have her an NGT inserted. Which of the following should the nurse do?
a. Follow the wishes of the husband, since the client cannot decide for herself
anymore.
b. Follow the wishes of the client as indicated in her advance directive
c. Refer the matter to the hospital’s legal counsel
d. Teach the husband on how to insert an NGT and let him do procedure himself.
6. A client is about to undergo an induction of her chemotherapy for AML. While reading
the chart of the client you noticed that doxorubicin, an emetogenic antineoplastic is one
of the agents that they will use in the induction. Knowing that this drug may cause severe
vomiting, which of the following should the nurse do in anticipation of the effects of the
drug?
a. Request the physician to replace doxorubicin with a low-emetogenic drug instead
b. Request the physician to order an antiemetic IV prior to induction
c. Report the incident to the quality assurance team as the physician did not observe
the procedures prior to administration of emetogenic drugs
d. Educate the client the use of guided imagery.
7. The client with AML has undergone a series of radiotherapy to suppress the bone marrow
in preparation for BMT. He was put in strict protective isolation. His relatives came and
want to see him. However, given the client’s condition, you cannot allow them to visit
him. Which of the following should the nurse do to address the client’s need for
psychosocial stimulation and support?
a. Let the family visit him one-by-one, observing them how they wash their hands
and letting them wear surgical masks.
b. Explain to them they cannot see or speak with client. However, let them write a
letter for him.
c. Let the family members use the intercom of the hospital to talk with the client.
d. Tell the family to leave the hospital as they might carry germs from outside.
 8. You admitted a client with ALL with an ANC of 2600/cu.mm is put in the unit’s private
room. His family members came and wanted to talk to him. Which of the following
members should the nurse not permit to enter the client’s room? Select all that apply.
a. The client’s pregnant wife who has just received the TT vaccine 2 days ago.
b. The client’s child who received his OPV 14 days ago
c. The client’s mother who was sneezing due to allergic rhinitis, as claimed
d. The client’s father who was diagnosed with hydronephrosis and BPH
9. A client with CLL and a platelet count of 30,000 was admitted to the unit. Which of the
following should the nurse refrain from doing?
a. Shaving the client using an electric razor
b. Providing a non-skid device in the client’s bathroom
c. Giving morphine SO4 IM every 6 hours using the finest needle
d. Putting the client’s bed at the lowest position possible
10. A 25 year-old client with AML on chemotherapy was admitted to the hospital due to
severe anemia for blood transfusion of 4 units of PRBC stat. While assessing the client,
you came to know that he has been converted a few weeks ago from a Baptist to
Jehovah’s Witness and he refused to have the transfusion. Which of the following should
the nurse do?
a. Explain the consequences of the client’s decision and let him sign a waiver of
refusal of treatment
b. Obtain a court order to force the client to accept the treatment
c. Confront your client, tell him you do not agree with his decision and tell your
supervisor to assign you to a different client.
d. Administer a sedative and do the transfusion while he is asleep.

CRITICAL THINKING

You are caring for a client, newly diagnosed with acute myeloid leukemia. He was presented
with the treatment options, however, for the past few days have been denying the diagnosis and
has been asking the nurse that he be transferred to another physician and a repeat BM aspiration
be done to another laboratory. As a nurse, what you should do? Referring to Elizabeth Kubler-
Ross’ stages of grieving, cite a scenario or narrative a client diagnosed with leukemia may
undergo or experience as he moves through these stages.

STAGES OF POSSIBLE NURSING

GRIEVING SCENARIOS/VERBALIZATIONS INTERVENTION/S
FROM THE CLIENT
DENIAL
ANGER
BARGAINING
DEPRESSION
ACCEPTANCE