LEUKE

MIA
Care of Child with Malignancy

University of the Philippines – Manila

SCHOOL OF HEALTH SCIENCES
Palo, Leyte
LEUKEMI
AMalignant neoplasms cells originally
derived from hematopoietic stem cells.

 The terms was first used by Virchow to

describe a reversal of the usual ratio of red
blood cells to white blood cells .
 Characterized by diffuse replacement of
bone marrow with unregulated,
proliferating, immature neoplastic cells.

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“ LEUKEMIA
Predominant cell line Duration

Lymphocytic Myelocytic Acute Chronic

“
 LYMPHO MYELOCY
•
CYTIC
Involve immature lymphocytes and
their progenitors that originate in the
bone marrow.
•
TIC
Involve the pluripotent myeloid stem
cells in bone marrow, interfere with the
maturation of all blood cells including the
granulocytes, erythrocytes and
thrombocytes.
ACUTE
LYMPHOCYTIC
LEUKEMIA
Disease Entity | Assessment |
Pathophysiology | Interventions |
Therapeutic Management

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ACUTE
LYMPHOCYTIC
LEUKEMIA
Lymphoblastic Leukemia (ALL)
 ALL accounts for 75% of Leukemias and
involves lymphoblasts or immature
lymphocytes.
 Production of Red blood cells (RBCs) and
platelets falls, and invasion of body organs
by the rapidly increasing WBC elements
begins.
 May be identifiable only at the immature
“blast cell” or “stem cell” stage.
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ACUTE
LYMPHOCYTIC
LEUKEMIA
Lymphoblastic Leukemia (ALL)

 The highest incidence of ALL is in children

between 2 and 6 years of age.
 The incidence of ALL is slightly higher in
boys than in girls, and the disease is seen
more often in white children than in
children of other races.

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 PATHOPHYSIOLO
GY
 All blood cells begin as immature cells (blast/stem
cells) that differentiate and mature into RBC’s,
platelets and various types of WBC’s.

 In leukemia, many immature or ineffective WBC’s

crowd out the developing normal cells .

 As the normal cells are replaced by leukemic cells,

anemia, neutropenia and thrombocytopenia
occur.

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 ETIOLOGY
 Both genetic predisposition and
environmental factors seem to play a
role.

 Familial leukemias are rare, but there

seems to be a higher incidence of leukemia
in siblings of affected children, with the
incidence increasing to 20% in identical
twins.

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 ETIOLOGY
 Individuals with chromosomal
abnormalities seem to have twentyfold
increased incidence.

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 ETIOLOGY
 Environmental factors:
• Ionizing radiation
• Chemicals (benzene, arsenic,
chloramphenicol, phenylbutazone and
antineoplastic agents)

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ASSESSMENT
Signs and Symptoms

 Pallor, low-grade fever, and lethargy

 Petechiae and bleeding from oral
mucous membranes and may bruise
easily
 Abdominal pain, vomiting, and
anorexia
 Bone and joint pain
 Headache or unsteady gait.

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ASSESSMENT
Physical Examination

 Painless, generalized swelling of lymph

nodes, especially of the submaxillary or
cervical nodes.

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 ASSESSMENT
Laboratory Result

 Variable leukocyte count

 Platelet count and hematocrit are low,

but the RBCs that are present are
normocytic and normochromic.

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 ASSESSMENT
Diagnostics

 Bone marrow aspiration

• Identify the type of WBC involved or to
document the type of leukemia
• More than 25% blast cells present, a
leukemia diagnosis is established.
• Bone marrow is aspirated at the iliac crest
rather than the sternum, both because this is
less frightening and because it yields more
marrow.

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 ASSESSMENT
Diagnostics

 Radiographs
• Long bones
• May reveal lesions caused by the invasion of
abnormal cells.

 Lumbar puncture
• May show blast cells in the cerebrospinal fluid
(CSF).

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 NURSING
DIAGNOSIS
 Risk for infection related to non-
functioning WBCs and
immunosuppressive effects of
therapy

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 OUTCOME
 Child’s temperature remains lower
than 98.6° F (37.0° C); no areas of
erythema or drainage are present on
skin.

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 INTERVENTIONS
 Report any indication of infection,
such as low-grade fever or behavior
that does not seem typical of the
child. The sooner the symptoms are
reported, the sooner anti-infective
therapy can begin.

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 INTERVENTIONS
 Children may be prescribed
prophylactic antibiotics to reduce the
possibility of infection. Parents may
be advised to limit visitors, especially
anyone with an infection, until the
child’s functioning WBC improves.

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 INTERVENTIONS
 To increase the functioning leukocyte
count, leukocytes may be transfused

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 NURSING
DIAGNOSIS
 Risk for deficient fluid volume related
to increased chance of hemorrhage
from poor platelet production

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 OUTCOME
 No evidence of hemorrhage is
present (no epistaxis, hematuria,
hematemesis); pulse rate and blood
pressure remain normal for age
group.

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 INTERVENTIONS
 Digital pressure is usually effective
to stop epistaxis.
 The application of Gelfoam soaked in
topical thrombin may be necessary.
In some children, postnasal packing
is necessary.
 Children may need a transfusion to
replace the lost blood volume.
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 INTERVENTIONS
 Advocate for intermittent infusion
devices such as heparin locks or
multilumen central venous catheters
that minimize the need for repeated
venipunctures.

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 NURSING
DIAGNOSIS
 Pain related to invasion of leukocytes

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 OUTCOME
 Parents and child state importance
of regular health maintenance visits;
child continues chemotherapy
regimen at home and keeps all
ambulatory appointments.

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 INTERVENTIONS
 Assess pain using a standard scale
for accuracy.
 Handle legs and arms gently to
minimize pain. Use of an alternating
mattress or sheepskin underneath
body joints helps to reduce skin
irritation caused by always resting in
the same position.
 Give analgesia as needed.
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 NURSING
DIAGNOSIS
 Ineffective health maintenance
related to long-term therapy for
leukemia.

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 OUTCOME
 Child states that pain is tolerable (if
infant, not crying).

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 INTERVENTIONS
 During the maintenance phase of
therapy, children can participate in
usual activities and should attend
regular school.
 Encourage parents to continue to
report promptly any sign of infection,
so antibiotic therapy can be started
early.

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 INTERVENTIONS
 Evaluation of children at follow-up
visits should include not only the
state of their blood but also whether
they are making forward-thinking
plans or thinking of themselves as
well children again.

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 MANAGEMENT
 95% of children will have a first remission

 If a child experiences a relapse, the chances

of long-term survival are reduced to
approximately 70%. Although remission
can be reinduced, the length of each
subsequent remission tends to be shorter
and less effective

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 MANAGEMENT
Disease Classification and Prognosis

 Leukemia is classified to define subgroups

of cells and to predict the usual response to
treatment

 Blasts with B-lymphocyte cell

characteristics can be recognized by the
presence of immunoglobulin and antigen–
antibody receptors on their surfaces

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 MANAGEMENT
Disease Classification and Prognosis

 B-lymphocyte cell types account for 85%

of instances of ALL. A specific antigen
found on cell surfaces has been named
CALLA, and cells are labeled as CALLA
positive or CALLA negative. The other
15% to 20% of children have T-
lymphocyte cell involvement. T
lymphocytes are also categorized as
CALLA positive or negative.
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 MANAGEMENT
Cure as a Goal
 A chemotherapy program is aimed at:
• achieving a complete remission or
absence of leukemia cells (induction
phase)
• preventing leukemia cells from
invading or growing in the CNS
(sanctuary or consolidation phase)
• administering delayed intensive
therapy
• maintaining the original remission
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(maintenance phase).
 MANAGEMENT
Cure as a Goal
 Chemotherapy in children is often
administered by means of a central
venous catheter or port

 Drugs frequently used to initiate a

remission include vincristine,
prednisone, L-asparaginase,
doxorubicin, and methotrexate. These
are given over a period of about 1 month.
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MANAGEMENT
Cure as a Goal
 Drug such as allopurinol is often
administered with chemotherapy, to
reduce the formation of uric acid.

 Keeping a child well hydrated also helps

maintain safe uric acid excretion.

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MANAGEMENT
Cure as a Goal

 A combination of intrathecal
administration (injection of drugs into
the CSF by lumbar puncture) of a drug
such as methotrexate and oral
administration of 6- mercaptopurine is
instituted to eradicate this source of
leukemic cells.

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MANAGEMENT
Cure as a Goal

 This is called a consolidation or

sanctuary phase, because no
“sanctuary” is given to malignant cells.
 The third phase of therapy intensifies
the assault against leukemic cells using
chemotherapeutic agents such as
vincristine, prednisone, L-asparaginase,
doxorubicin, cyclophosphamide,
cytosine arabinoside (ARA-C), or 6-
thioguanine.
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MANAGEMENT
Maintenance and Monitoring

 Aims to eliminate completely any

remaining leukemic cells, so that the
child’s immune system can complete the
eradication.

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MANAGEMENT
Standard maintenance therapy
 Includes a combination of daily 6-
mercaptopurine, weekly methotrexate,
and sporadic vincristine and prednisone,
and intrathecal methotrexate. This is
continued for 2 to 3 years.
 A drug such as leucovorin is usually
given after systemic methotrexate, to
neutralize its action and protect normal
cells from the effect of the drug.

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MANAGEMENT
Standard maintenance therapy

 During the maintenance phase, the

child’s blood values must be monitored
at least monthly

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MANAGEMENT
Standard maintenance therapy

 If a bone marrow study during the

maintenance phase shows that leukemic
cells are again evident, a new induction
phase will be initiated, followed by a
new sanctuary, intensification and
maintenance phase.

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MANAGEMENT
Standard maintenance therapy

 Children who are free of disease for 4

years are considered cured, and their
maintenance therapy can then be
stopped.
 Bone marrow transplantation or
immunotherapy may be used with
children who do not respond well to
standard therapy.

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 SALA
MAT!
martensson@example.com
678-555-0128

University of the Philippines – Manila

SCHOOL OF HEALTH SCIENCES
Palo, Leyte