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Leukemias

It is a malignant disorder involving bone marrow dysfunction


manifested by anemia, thrombocytopenia, and abnormal
proliferation of white cells, which results in harmful filtration into
tissues. It is the most common malignancy in childhood (30%), peak
incidence 2-8 years of age. Incidence among males is greater than
females 2:1.
Etiology:
Although the exact cause is unknown, but multiple factors
believed to be responsible: ionizing radiation, chemicals (benzene
compound, heavy metals), drugs (Alkylating agents), and
chromosomal abnormalities (Down syndrome), and familial
predisposition.
Pathophysiology:
There will be a bone marrow failure resulted from overgrowth
of leukemic cells in the marrow (immature blast cells).
Both red cells precursors and megakaryocytes from which platelets
are formed are decreased leading to anemia and epistaxis, and easy
bruisability.
Since white blood cells are decreased infection is common.
Leukemic cells will proliferate (migrate out) of bone marrow
and infiltrate in lymph nodes spleen, liver leads to Hepatosplenomegaly and lymphoadenopathy.
Classification:
Leukemia is classified according to its predominant cell type
and level of maturity as described by the following:
Lympho
for Leukemias involving the lymphoid or
lymphatic system.
Myelo
for those of myeloid (bone marrow) origin.
Blastic and acute
for those involving immature cells.
Cytic and chronic
for those involving mature cells.
In children two forms are generally recognized:
Acute lymphoid leukemia (A.L.L.) and acute nonlymphoid
leukemia (A.N.L.L) or (A.M.L).
A.L.L includes lymphatic, lymphocytic, lymphoblastic and
lymphoblastoid leukemia.
A.N.L.L. type includes granulocytic, myelocytic, monocytic,
myelogenous, monoblastic and monomyeloblastic.

Assessment:
It is according to the pathological effect:
Organ or Tissue

Consequences

1. Decreased RBCs
Bone Marrow
anemia.
Dysfunction
2. Neutropneia
infection.
3. Decreased platelets
bleeding tendancy.
4. Invasion of bone
marrow
bone weakness.
5. Invasion of
periosteum
increase pressure.
1. Infiltration.
Liver, Spleen and 2. Enlargement.
Lymph gland
3. Eventual fibrosis.
1. Increased intracranial
CNS Meninges
pressure.
2. Ventricular
enlargement.
3. Meningeal irritation.
Hypermetabolis
m

1. Cell deprivation of
nutrients by invading
cells.

Manifestation
Pallor, fatigue, dyspnea
exertion.
Fever
Hemorrhage
(Petechia)
Tendency toward fractures.
Pain (pain in joint,
episodes of abdominal
pain)
1.
2.
3.
1.
2.
3.
4.
5.
6.
7.
8.

Hepatomegaly.
Splenomegaly.
Lymphoadenopathy.
Severe headache.
Vomiting.
Irritability.
Lethargy.
Papilledema.
Eventual coma.
Pain.
Stiff neck and back.

1.
2.
3.
4.
5.
6.

Lassitude.
Muscle wasting.
Weight loss.
Anorexia.
Fatigue.
Low-grade fever.

Diagnostic Evaluation:
Leukemia is usually suspected by the history, physical
manifestations and peripheral blood smear that contains immature
forms of leukocytes, frequently combined with low blood counts.
Definitive diagnosis is based on bone marrow is hypercellular with
primarily blast cells. Once the diagnosis is confirmed, a lumber
puncture is performed to determine if there is any C.N.S.
involvement.

Therapeutic Management:
Treatment of leukemia involves the use of chemotherapeutic
agents with or without irradiation in three phases:
1. Remission induction therapy: which is determined by the
absence of clinical evidence of disease and the presence of
less than 5% blast cells in the bone marrow.
2. C.N.S. preventive therapy and consolidation, which
provides treatment in those areas of the body normally
protected from cytotoxic, drug levels.
3. Maintenance therapy, which serves to maintain the
remission phase.
In some children a fourth phase, reinduction therapy is needed
to treat a relapse.
1. Remission Induction: (Eradicate leukemic cells)
Almost immediately after confirmation of the diagnosis,
induction therapy is begun and lasts 4 to6 weeks. The principal
drugs used for induction in A.L.L. are:
Corticosteroids. (Especially Prednisone).
Vincrisline Sulfate Oncovin.
Adramycin.
2.C.N.S. preventive therapy / Consolidation:
(Prevention of meningeal leukemia)
Treatment of the C.N.S consists of prophylactic therapy with
intrathecal chemotherapy. This therapy is reserved for high-risk
patients and those with C.N.S. disease. C.N.S. therapy usually
begins during the first 6 to 8 weeks after diagnosis and is continued
for a specific period of time.
Once complete remission is obtained, a period of intensified
treatment is administered to further reduce the leukemia burden
(Consolidation).
3.Maintenance therapy:
Maintenance therapy is begun after completion of successful
induction and consolidation therapy to preserve the remission and
further lessen the number of leukemic cells.
4.Reinduction therapy: (Fourth phase)
When the presence of leukemic cells are observed in the bone
marrow, C.N.S. or other sites, the child has relapsed. Therapy for the

child who has relapsed includes reinduction. Other drugs not


previously used.
Bone marrow transplantation:
It has been used successfully for treating children who have
A.L.L.. and A.N.L.L. bone marrow transplantation is not
recommended for children with A.L.L. during the first remission
because of the excellent results possible with chemotherapy.
Because of the poor prognosis in children with A.N.L.L.
transplantation may be considered during the first remission.

Prognosis:
The most important factors for determining long-term survival
for children with A.L.L. in addition to treatment are:
1. The initial WBCs count.
2. The childs age at the time of diagnosis.
3. The type of cell involved.
4. The sex of the child.
Children diagnosed between 2 and 9 years of age have
consistency demonstrated a better outlook than those
diagnosed before 2 or after 10 years of age, and females
appear to have a more favorable prognosis than male.
Nursing care plan for the child with leukemia:
Nursing diagnosis:
1. High risk for infection related to depressed body defenses.
Goal:
Patient will experience minimized risk of infection.
Intervention:
Place child in private room.
Advise all visitors and staff to practice hand washing.
Screen all visitors and staff for signs of infection.
Use aseptic technique.
Evaluate child for any potential sites or infections.
Provide nutritionally complete diet for age.
Administer antibiotics as prescribed.
Expected Outcome:
Child doesnt come in contact with infected persons or
contaminated articles.
Child consumes diet appropriate for age.
Nursing diagnosis:
2. High risk for injury (hemorrhage) related to interference with cell
proliferation.
Goal:
Patient will exhibit no evidence of bleeding.

Intervention:
Use all measures to prevent infection, especially in
ecchymotic area.
Use local measures to stop bleeding.
Restrict strenuous activity that could result in accidental
injury.
Involve child in responsibility for limiting activity when
platelet count drops.
Administer platelets as prescribed.
Expected Outcome:
Child exhibits no evidence of bleeding.

Nursing diagnosis:
3. Altered nutrition less than body requirement related to loss of
appetite.
Goal:
Patient will receive adequate nutrition.
Intervention:
Encourage parents to relax pressure placed on eating.
Allow child any food tolerated. Improve quality of food
selections when appetite increases.
Stress expected increase in appetite from steroid.
Take advantage of any hungry period, sever small snakes.
Allow child to be involved in food preparation and selection.
Make food appealing.
Remember usual food practices of children in each age
group.
Expected Outcome:
Nutrition intake is adequate.
Nursing diagnosis:
4. High risk for fluid volume deficit related to nausea and vomiting.
Goal:
Patient will experience no vomiting.
Intervention:
Administer initial dose of antiememtic before onset of
nausea and vomiting.
Avoid foods with strong odors.
Uncover hospital food tray outside of childs room to reduce
food orders.
Mouths care frequently.
Expected Outcome:
Child retains food and fluids.
Nursing diagnosis:

5. Altered mucous membranes related to administration of


chemotherapeutic agents.
Goal:
Patient will not develop oral mucostis.
Intervention:
Inspect mouth daily for oral ulcers, avoid oral temperatures.
Oral hygiene as soon as a drug is used that caused oral
ulcers.
Use soft sponge toothbrush, cotton tipped applicator or
gauze wrapped finger.
Administer frequent (at least every 4 hours and after meals)
mouthwashes (normal saline or sodium bicarbonate solution).
Apply local anesthetics to ulcerated areas before meals and
as needed.
Serve bland, moist, soft diet.
Encourage fluids; use a straw to help bypass painful areas.
Report evidence of ulcers to doctor.
Avoid juices containing ascorbic acid lemon swabs and hot
or cold food.
Administer antiinfective medication as ordered.
Expected Outcome:
Mucous membrane remains intact.
Ulcer shows evidence of healing.
Goal: (2)
Patient will not develop rectal ulceration.
Intervention:
Wash perineal area after each bowel movement.
Use warm bath or tub baths.
Apply protective skin barriers (transparent film dressings,
occlusive ointment) to perineal area.
Observe constipation resulting from childs voluntary refusal
to defecate or from chemotherapy.
Avoid rectal temperature and suppositories.
Record bowel movement, use stool softener to prevent
constipation.
Expected Outcome:
Rectal mucosa remains clean and intact.
Ulcerated areas heal without complications.
Child has regular bowel movements.
Nursing diagnosis:
6. Impaired skin integrity related to administration of
chemotherapeutic agents.
Goal:
Patient will maintain skin integrity.
Intervention:

Provide skin care especially in mouth and perineal regions.


Change position frequently.
Encourage adequate caloric-protein intake.
Expected Outcome:
Skin remains intact.
Nursing diagnosis:
7. Pain related to diagnosis and treatment.
Goal:
Patient will experience minimal or no pain.
Intervention:
Avoid excessive noise or light.
Place all commodities with easy reach.
Use gentle, minimal physical manipulation.
Avoid pressure on painful relief from analgesics.
Experiment with using heat or cold on painful areas (Use
cautiously because of easy skin breakdown).
Change position frequently, if difficult for child coordinate
with pain relief from analgesics.
Avoid pressure on bony prominences.
Administer analgesics as prescribed.
Avoid aspirin or any of its compounds.
Expected Outcome
Child rests quietly, exhibits no evidence of discomfort
verbalizes no complaints of discomfort.
Nursing diagnosis:
8. Body image disturbance related to loss of hair and moon face.
Goal: (1)
Patient will exhibit positive coping.
Intervention:
Administer good scalp hygiene.
Provide adequate covering during exposure to sunlight,
wind or cold.
Stress that hair begins to regrow in 3 to 6 months and may
be a slightly different color or texture.
Expected Outcome:
Child verbalizes concern regarding hair loss.
Child appears clean, well groomed and attractively dressed.
Goal: (2)
Patient will exhibit adjustment to altered facial appearance.
Intervention:
Stress that this reaction is temporary.
Evaluate weight gain carefully.
Encourage early and consistent interaction with peer.

Expected Outcome:
Child resumes former activities and relationship within
capabilities.
Nursing diagnosis:
9. Fear related to diagnostic tests, procedures, treatment, and
prognosis.
Goal:
Patient will exhibit reduced fear related to diagnostic
procedures and tests.
Intervention:
Explain procedure carefully at childs level of understanding.
Explain responsibility of child.
Provide child with some means of involvement with the
procedure.
Implement distracting technique and pain reduction
techniques as indicated.
Expected Outcome:
Child readily responds to verbal directives and exhibits less
fear.
Child repeats information accurately.

Nursing diagnosis:
10. Altered family process related to a child with life threatening
disease.
Goal:
Family will receive adequate support.
Intervention:
Teach parents about disease process.
Explain all procedures that will be done to child.
Schedule time for family to be together.
Help family for future, especially toward helping child live a
normal life.
Encourage family to discuss feelings regarding childs
course prior to diagnosis and childs prospects for survival.
Discuss with family how they will tell child about outcome of
the disease.
Expected Outcome:
Family expresses feelings and concerns and spends time with child

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