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Student Presentation



General Information

Acop, Joyce Ann Bantali, Daryl Christine Bucang, Loraine Dicam, Safrone Na-oy, Hilda Jean Nebrija, Flordeliza Ngina, Grettle Mae Tauli, Danielle Thomas,

II. Epidemiology III. Risk Factors IV. Pathophysiology V. Diagnosis VI. Treatments & Management VII. Nursing Considerations

but then the myeloblasts don't turn into healthy granulocytes. Usually. the stem cells turn into myeloblasts. ________________________________________________________________________________ Types of Leukemia 1.  Greek leukos = "white" and aima = "blood". or the lymphoid stem cell . Acute Myeloid Leukemia (AML) -Myeloid stem cells don't mature and cannot function normally. Chronic Leukemia a. Other Types of Leukemia a. -immature cells crowed out other healthy blood cells 3.I. -immature cells crowed out other healthy blood cells 2. A person who has leukemia suffers from an abnormal production of blood cells. Chronic Lymphoid Leukemia (CLL) b. General Information Leukemia is a neoplastic proliferation of one particular cell type. generally leukocytes (WBC). Acute Leukemia a. Chronic Myeloid Leukemia (CML -About 2 to 3% of children with leukemia have CML. Juvenile myelomonocytic leukemia (JMML) -In about 1-2% of children with leukemia .  The defect originates in the hematopoietic stem cell. so they cannot fight infection well -too many immature lymphocytes which crowd out other types of health blood cells -Cancer is more common in B cells than T cells. but don’t turn into healthy granulocytes. Usually. the myeloid. -Myeloid stem cells don't mature and may not function normally. the stem cells turn into myeloblasts.  Is a cancer of the blood or bone marrow. -s/s: Low RBC (anemia) and low platelet (prone to bruising or bleeding) b. Acute lymphocytic (lymphoblastic) leukemia (ALL) -Lymphocytes do not mature the way they should.

-very hard to treat.000 >13. So it often doesn’t need treatment right away. Spleen may become swollen and painful. of New Cases each year >15.-mainly affects children <4 y/o. Epidemiology . bruising easily.000 >5. Type of Leukemia CLL CML ALL AML Type of WBC Affected Lymphocytes Myeloid Cells Lymphocytes Myeloid Cells Development Slow Slow Fast Fast No. b. weight loss. Hairy Cell Leukemia (HCL) -very rare cancer that causes the body to make too many WBC which looks hairy under a microscope. *current treatment: chemotherapy and stem cell transplant. and repeated infections.000 Common People Affected Age 55y/o and above Mainly adults Young Children Adults and Children Signs and Symptoms o Feeling weak. adults in their 50s and is not seen in children or teens. tired or generally unwell o Frequent Infections o Unexplained Fevers o Abnormal Bruising or Excessive Bleeding o Bone and Joint Pain o Enlarged Lymph Nodes o Abdominal Discomfort o Easy Shortness of Breath II. -may grow very slowly or it may not get worse. fever.000 Near 5. -common in men. -s/s: weakness.

720 people are expected to die from leukemia.610 people are expected to be diagnosed with leukemia.749) as children and adolescents (3. Accounts for 60%of all childhood cancers among Filipino children 80%could be potentially cured Only 16-20%actually attain long term survival Childhood leukemia and lymphoma relative survival was much lower in Filipinos living in the Philippines (32. with approximately 257. Approximately 31 % more males are living with leukemia than females. Leukemia accounts for about 33% of cancer cases in children aged 0-14 • • • • • • B. ages 0-14 years). National 3. 23. leukemia is expected to strike approximately 12 times as many adults (43. 48. In 2013.605. Leukemia causes almost one-third of all cancer deaths in children and adolescents younger than 15 years Most cases of leukemia occur in older adults. the median age at diagnosis is 66 years.500– Estimated number of children diagnosed every year. In 2013.000 people are diagnosed with leukemia each year. International an estimated 350.9 and 47.000 deaths annually. More males than females are diagnosed with leukemia and die of leukemia. Leukemia is diagnosed 10 times more often in adults than in children. In 2013.         A.7%) More than 2/3 late stages at diagnosis .

although she also affirmed that such follow-ups and consultations in BGHMC is increasing because of the free medicines given under the DOH program and the capability of the hospital in terms of experts and their capacity to handle such cases. Genetic Disorders: • Li-Fraumeni syndrome: This is a rare condition caused by change in the TP53 tumor suppressor gene.    III. In 2011 alone. the other twin has about a 1 in 5 chance of getting leukemia as well. GENETICS Family history: Most leukemia have no familial link. If an identical twin develops childhood leukemia. Igama also stressed that it does not reflect the real number of cases they see. may put you at an increased risk for developing the disease. Leukemia has the most number of cases. Dr.C. which is why the DOH has a program on this. Of the recorded 537 cases in BGHMC for 2011. Risk Factors GENERAL: : “WHITE MALE OVER 50” Gender: Leukemia occurs more often in men than women. Local  Leukemia comprises about 13 % of the cancer cases in the country and about 65 % of leukemia patients are children. first degree relatives of CLL patients. Race: Leukemia is more common among white people than other races. I. Age: 60% to 70% of cases of leukemia are diagnosed in patients ages 50 and over. 27 % cases leukemia cases in children. they recorded 537 leukemia consultations. However. People with this change have an increased risk of developing several . or having an identical twin who has or had AML or ALL.

including leukemia. LIFESTYLE Smoking: Smoking is a considerable risk factor for leukemia. which grows much faster. immune deficiency. Down syndrome has also been linked with transient leukemia. Alcohol Consumption: Some studies have suggested that if a mother drinks a lot of alcohol during pregnancy it might increase the risk of leukemia in her child. and brain tumors. • Inherited immune system problems: • Ataxia Telangiectasia: Ataxia telangiectasia (A-T) (also referred to as Louis–Bar syndrome) is a rare. • Down syndrome (trisomy 21): Children with Down syndrome are many times more likely to develop either acute lymphocytic leukemia (ALL) or acute myeloid leukemia (AML) than are other children. Neurofibromatosis: is a genetically-inherited disorder in which the nerve tissue grows tumors (neurofibromas) that may be benign and may cause serious damage by compressing nerves and other tissues. with an overall risk of about 2% to 3%. thrombocytopenia (low platelet count). It is estimated that 1 in 4 cases of AML are caused by smoking. especially a type of leukemia called acute myelogenous leukemia. Fanconi anemia: is the result of a genetic defect in a cluster of proteins responsible for DNA repair. and bloody diarrhea (secondary to the thrombocytopenia). Bloom Syndrome: is a rare autosomal recessive disorder characterized by short stature and predisposition to the development of cancer. Wiskott-Aldrich syndrome: is a rare X-linked recessive disease characterized by eczema. • • Klinefelter syndrome: This causes infertility. The lifetime risk of cancer developing in a person with NF1 is estimated to be about 7%. neurodegenerative. invades nearby structures and sometimes metastasizes (spreads) to other regions of the body. Ataxia refers to poor coordination and telangiectasia to small dilated blood vessels. both of which are hallmarks of the disease. FA patients are at elevated risk for the development of acute myeloid leukemia (AML). inherited disease causing severe disability. adrenal gland cancer. *Vit B12 and Folate Deficiency: Can present as leukemia . This generally happens when a benign (non-cancerous) neurofibroma turns into a cancerous form called sarcoma. or AML. bone or soft tissue sarcomas.kinds of cancer. prevents normal development of some male features. breast cancer. • • II. and is linked to a slightly increased risk of developing leukemia.

Medical attention should be sought. People. and diarrhea within hours. TYPE OF RADIATION 1. Amount of Radiation 0-5 rem Duration of Exposure Short periods or over a long period Short periods or over a long period Short periods or over a long period Short time Radiation Doses and Expected Effects Effect No observable health effects. ENVIRONMENTAL FACTORS A. turning them into potentially toxic compounds which interact with healthy molecules and cause damage. Ionizing radiation: Has enough energy to break certain chemical bonds. • Radiation therapy: Another source of exposure to high levels of radiation is medical treatment for cancer and other conditions. or acute lymphocytic leukemia. rarely.000 rem Short time Short time • Diagnostic x-rays: It's not known yet whether this low level of radiation to children or adults is linked to leukemia. Researchers are studying whether having many x-rays may increase the risk of leukemia. Radiation Exposure People exposed to very high levels of radiation are much more likely than others to get acute myeloid leukemia. and dyes) may cause AML in adults and. Loss of hair and appetite occurs within a week. Weak and is unable to cause cell damage that could lead to cancer. B. are at increased risk of leukemia. Non-ionizing radiation: Has sufficient energy only for excitation. in children. 5-10 rem Effect is either nonexistent or too small to observe Above 10 rem the chances of getting cancer are slightly increased. remove electrons from atoms. who survive atomic bomb explosions. especially children. harms a molecule directly. • Atomic bomb explosions: Very high levels of radiation have been caused by atomic bomb explosions (such as those in Japan during World War II). Direct radiation action . chronic myeloid leukemia. Lead to death in a few days Lead to death in a few hours 100-200 rem Short Time Long Periods 200-300 rem 300-500 rem Short Time Short Time 500-1200 rem >10. 10-50 rem 50-100 rem Long periods Likely cause some observable health effects Short-term blood cell decreases for doses of about 50 rem Increase the chances of getting cancer Nausea and Fatigue Increase a person’s chances of getting cancer Nausea and vomiting within 24-48 hours. Medical attention must be sought for survival. . Indirect damage . Nausea. plastics. 2. as for example when radiation interferes with a molecule of DNA. Radiation therapy can increase the risk of ionizing molecules. Exposure to other chemicals • Benzene: Exposure to chemicals such as benzene (a solvent used in the cleaning industry and to manufacture some drugs. 2. half of the people exposed to radiation at this high level will die if they receive no medical attention. causing cell damage. and damage DNA in our cells that can lead to cancer HOW RADIATION CAUSE CELL DAMAGE: 1.III.

Fludarabine (FLUDARA): for CLL d. adult T-cell leukemia and other types of leukemia are not contagious. Pentostatin (NIPENT): for CLL *Leukemias caused by chemotherapy usually develop within 5 to 10 years of treatment and tend to be hard to treat. Human T-cell leukemia virus type I (HTLV-I): People with HTLV-I infection are at increased risk of a rare type of leukemia known as adult T-cell leukemia. later in life. alkylating agents: cyclophosphamide (CYTOXAN) and chlorambucil (LEUKERAN) b. • IV. epipodophyllotoxins: etoposide and teniposide c. C. either during pregnancy or early childhood. IV. Immune System Suppression: Patients getting intensive treatment to suppress their immune function (mainly organ transplant patients) have an increased risk of certain cancers. OTHERS • • Myelodysplastic syndrome and certain other blood disorders: People with certain blood disorders are at increased risk of acute myeloid leukemia. Although the HTLV-I virus may cause this rare disease.PATHOPHYSIOLOGY External and Internal DNA_Changes Activate Oncogene Deactivate TumorSuppressor Gene • Altered Gene Structure • Regulation of Cellular Proliferation of Immature Cells Lymphoid Stem Myeloid Stem . Examples of Chemotherapy Drugs associated to Leukemia a. Some studies have also found a possible increased risk among mothers with workplace exposure to pesticides before birth.• • Pesticides: Several studies have found a possible link between childhood leukemia and household exposure to pesticides. Phosphocol P32: Some reports have linked it to leukemia when the drug has been prescribed without FDA approval to treat children with bleeding between the joints caused by hemophilia. Chemotherapy Children and adults treated for other cancers with certain chemotherapy drugs have a higher risk of getting a second cancer. usually AML or ALL.

. The patient must lie flat for several hours afterward to keep from getting a headache.A C AM CML V.  bone marrow biopsy. the doctor will examine the body to check general signs of health. The doctor will then use a long. which is found inside red blood cells. The lab will check the fluid for leukemia cells or other signs of problems. bone marrow.only sure way to know whether leukemia cells are in the bone marrow. Biopsy (removal of tissue to look for cancer cells). such as lumps or anything else that seems unusual.  Additional techniques that may be used to further classify the type of leukemia include flow cytometric immunophenotyping and genetic analysis  Physical Exam and Medical History During the physical exam.The doctor will remove some of the cerebrospinal fluid (the fluid that fills the spaces in and around the brain and spinal cord). • Blood tests: check the level of blood cells because leukemia causes:  A very high level of white blood cells  Low levels of platelets  Low levels of hemoglobin.  bone marrow aspiration.  Exams and Tests Exams and tests that are used to make a leukemia diagnosis may include blood tests and a biopsy. and treatments. Cytogenetic -. Healthcare providers will also take and review a history of the patient's health habits. past illnesses.use a needle to remove samples of bone marrow.use of a very thick needle to remove a small piece of bone and bone marrow. The doctor removes some bone marrow from the hipbone or another large bone then examined by pathologist under a microscope. including checking for signs of disease. DIAGNOSIS  Leukemia is typically diagnosed via abnormal results on a full blood count followed by examination of a blood film. thin needle to remove fluid from the spinal column. The lab may also check the blood for signs that leukemia has affected the liver and kidneys. or lymph nodes.  Usually confirmed on a bone marrow aspirate and/or trephine biopsy looking at cell morphology and bone marrow architecture.The lab will look at the chromosomes of cells from samples of peripheral blood. The procedure takes about 30 minutes and is performed with local anesthesia. • • • Spinal tap -.

Refractory: Leukemia fails to go into remission following treatment. extramedullary blast proliferation. Fluorescent in situ hybridization (FISH) . -More than 5% of the cells in the bone marrow are blasts (leukemia cells). Child Untreated: No treatment given except to reduce symptoms. -There are signs and symptoms of leukemia.A test in which the cells in a sample of blood or bone marrow are examined under a microscope to determine if malignant (cancerous) lymphocytes began from the B lymphocytes or the T lymphocytes.similar to cytogenetic testing. cytogenetic evidence of clonal evolution Peripheral blood blasts ≥ 20% of peripheral blood white blood cells or nucleated bone marrow cells. b. Chest x-ray -.• Immunophenotyping . no treatment received except to relieve symptoms) -The complete blood count is abnormal. and no signs or symptoms of leukemia are present. It uses special fluorescent dyes that only attach to specific parts of particular chromosomes changes like translocations from blood or bone marrow sample visible under a microscope in standard cytogenetic tests. It is very accurate and can usually provide results within a couple of days. Recurrent: Leukemia has returned following treatment and period of remission. and large foci or clusters of blasts on bone marrow biopsy Blast crisis Acute Lymphoid Leukemia a. Adult ALL in remission (ALL has been treated) -The complete blood count is normal. .The x-ray can reveal signs of disease in the chest. -5% or fewer of the cells in the bone marrow are blasts (leukemia cells). -There are no signs or symptoms of leukemia other than in the bone marrow. persistent thrombocytopenia (< 100 × 109/L) unrelated to therapy or persistent thrombocytosis (> 1000 × 10 9/L) unresponsive to therapy. Adult Patient Untreated adult ALL (It is newly diagnosed. In Remission: Treatment has been given and amount of white blood cells in the blood and bone marrow are normal. as well as some changes too small to be seen with usual cytogenetic testing. increasing white blood cells and spleen size unresponsive to therapy. • • Staging CML phase WHO definition Chronic Peripheral blood blasts fewer than 10% in the blood and bone marrow stable phase Accelerated phase Blasts 10-19% of white blood cells in peripheral and/or nucleated bone marrow cells .

HLA-matched relative (most often a sibling) HLA-matched unrelated donor HLA miss-matched family member Unrelated umbilical cord blood 2. Stem Cell Transplantation (Hematopoietic Progenitor Cell Transplantation) Stem Cell – immature. Before Receiving Stem Cell Transplantation: a. Conditioning regimen . Types 1. b.involves intensive treatment to destroy as many leukemic cells as possible. *human leukocyte antigens test: comparison of the patient’s blood and tissue type against blood samples from the donor. less toxic doses of chemotherapy and/or Total Body Irradiation (TBI) before the transplant 2. Leukemia treatment commonly involves a combination of therapies. Process 1. Reduced-intensity conditioning (a “mini-allogeneic transplant”) . and then given back to the patient. suppress the disease and reduce the possibility of a relapse. d. The stem cells are then harvested.stem cells are taken from a matching donor. c. ***For patients with leukemia. B. Autologous Stem Cell Transplant . such as chemotherapy . a.stem cells are collected from the patient themselves. Risk Low Intermediate Intermediate High High Clinical/Morphological Features Lymphocytosis alone Lymphocytosis with lymphadenopathy Lymphocytosis with lymphadenopathy and splenomegaly or hepatomegaly Lymphocytosis with anemia Lymphocytosis with anemia and thrombocytopenia TREATMENT/MANAGEMENT Treatment for leukemia can range significantly from observation (watchful waiting) to high-dose chemotherapy and stem cell transplantation.uses lower. immunotherapy and radiation therapy. a stem cell transplant can be used to infuse healthy stem cells into the body to stimulate new bone marrow growth. I. b. blood-forming cells that can develop into any of the three main types of blood cells can be found in the bone marrow.RAI Classification of CLL Stage 0 I II III IV VI. circulating (peripheral) blood and umbilical cord blood. frozen and stored.Transplant Proper Stem cells (SC) given intravenously (about 1 hour) SC enters bloodstream . A. Allogeneic Stem Cell Transplant .

 help target leukemia cells that have spread to the central nervous system B.a plastic.Intrathecally – into the fluid surrounding the brain and spinal cord  highly-targeted method of delivering leukemia treatment  allows the chemotherapy to go where it can directly destroy the cancer cells  given directly into the cerebrospinal fluid to reach leukemia cells in the central nervous system  delivered either through a lumbar puncture. or through a special device placed under the scalp (Ommaya Reservoir. Because each medication destroys tumor cells in different ways. *** Chemotherapy for leukemia often consists of giving several drugs together in a set regimen.used to destroy any remaining leukemia cells that cannot be seen in the blood or bone marrow c. dome-shaped device.Intravenously – injection into the vein * central venous access catheter is placed to deliver chemotherapy.Orally – by mouth (pill form) 2. Chemotherapy . A. 3. Induction Chemotherapy . patient is at risk of graft-versushost-disease (GVHD): a condition where donated cells attack the patient’s tissues. Maintenance chemotherapy – may be received by patients with ALL. Chemotherapy for Acute Leukemias –begins with Induction Chemotherapy followed by Intensification (consolidation) chemotherapy a.a combination of drugs is used to destroy as many leukemia cells as possible and bring blood counts to normal b. Intensification (consolidation) chemotherapy . II. Follow-up: blood counts should be checked on a frequent basis to monitor process. Possible Side Effect: After allogeneic stem cell transplant. Types of Chemotherapy 1. with a catheter attached to the underside used to deliver chemotherapy drugs to the central nervous system [brain and spinal cord]).uses anticancer drugs to destroy tumor cells in the body by impeding their growth and reproduction.stem cells travel to the bone marrow bone marrow begin to produce new blood cells ( engraftment) ***The transplant restores the supply of normal cells that have been destroyed by the intensive therapies. used to reduce the risk of the disease recurring after treatment 2. Routes of Administration 1. . 3. a combination of drugs may make the cells more vulnerable to treatment. give intravenous fluids and obtain blood samples to minimize the discomfort of multiple needle pricks. Chemotherapy for Chronic Leukemias – common chemotherapy is given orally. C.

to prevent the cells from spreading and/or to relieve symptoms . etc. diarrhea and shortness of breath. or they may be attached to chemotherapy drugs to deliver high concentrations of the drugs directly to the tumor cells -Potential Side Effects: flu-like symptoms (fever. Fatigue 5.). to monoclonal antibodies to target and destroy leukemia cells.g.. Chronic Myeloid Leukemia – patient may receive Gleevec® (imatinib). Nausea 2. Chemotherapy-Related Side Effects 1. headache. chills. Neuropathy 6. Yttrium-90). Chronic Lymphocytic Leukemia . Radioimmunotherapy -combines radiation therapy and immunotherapy -works by attaching radioactive molecules.uses the body’s own immune system to block the growth and spread of cancer cells by preventing the cells from dividing or directly destroying them *Targeted drug therapy . A.laboratory-produced antibodies (proteins) that locate and bind to specific substances (antigens) on cancerous cells and eventually destroy the cells B. -directly target leukemia cells. *Monoclonal antibodies (MAbs or MoAbs) . Lowered Blood Cell Counts ___________________________________________________________________________ III. called radioisotopes (e. Taste Changes and Mouth Sores 3.may receive FCR (fludarabine. Sexual Dysfunction 8. Immunotherapy/Targeted Drug Therapy *Immunotherapy (biological therapy/biotherapy) . helping to reduce damage to healthy cells and minimize side effects -usually in combination with chemotherapy -commonly used for the treatment of CLL: Campath® (alemtuzumab) and Rituxan® (rituximab). Sprycel® (dasatinib) and Tasigna® (nilotinib) b. Monoclonal Antibody Therapy -may be used alone to destroy leukemia cells.a.blocks the growth and spread of leukemia cells by interfering with specific molecules needed for growth. cyclophosphamide and rituximab) and bendamustine C. Hair Loss 7. skin rash. Cardiotoxicity 4. Radiation Therapy/Radiotherapy -uses high-energy X-rays to destroy leukemia cells. nausea. IV.

and can help to reduce swelling in the lymph nodes. Restrict fresh flowers and plants. TBI helps to reduce the likelihood that the body will reject the transplant.  EBRT helps to minimize damage to healthy tissues and reduce side effects. Nursing Considerations 1.Total Body Irradiation (TBI) -advanced radiation therapy that can be used to destroy cancerous cells anywhere in the body -often serves as part of the preparation process for leukemia patients who will undergo chemotherapy and stem cell transplantation. family and client). or swollen lymph nodes. Maintain meticulous hand washing (staff. liver or spleen Process: i. Restrict visitors with colds. Institute measures to prevent exposure to known or potential sources of infection: a. diarrhea. f. and skin changes VII. -Total body irradiation treatments are painless and treatment time is relatively short. flu or infections. c. -The lungs are shielded to lower the risk of damage from the radiation. Maintain protective isolation in accordance with institutional policy (placing in a private room) b. EBRT can deliver radiation from any angle. It can also help to treat pain from bone damage caused by leukemia cells growing in the bone marrow) Common Types 1. fatigue.  Unlike chemotherapy. and shape radiation beams to the contour of the tumor. which circulates through the body. including the type of leukemia and symptoms. e. Restrict fresh fruits and vegetables. Post a sign over the washbasin in the room as a reminder. painless outpatient procedure. 2. (i. d. .e. Diagnostic and imaging tools will be used to pinpoint the treatment area(s) and determine the correct radiation angles and dosage. ii. radiation therapy may be used to relieve pain or discomfort caused by an enlarged liver or spleen. External Beam Radiation Therapy (EBRT)    uses a machine to direct high-energy rays from outside the body onto cancerous tissues within the body common option for chronic lymphocytic leukemia (CLL). mouth sores. -Potential Side Effects: nausea. ERBT is targeted to a specific area. Provide good perianal hygiene twice daily and after each bowel movement.-The area treated with radiation therapy and the dose given is based on specific leukemia diagnosis. Linear accelerator(a special X-ray) will deliver high-energy rays Advantages:  It’s a fast. -linear accelerator: delivers radiation therapy to the entire body Advantages: -When used before a stem cell transplant.

aspx National Cancer Institute (2013. 2013. 2013.g.g. IFC insertion. Provide for periods of rest alternating with http://leukemia. 2013. Retrieved July 13. from Medscape: http://cancer. January 17). Retrieved July 11. VIII. Lippincott Williams and Wilkins. (2013.References 5th Edition. RATIONALE: Understanding the temporary nature of disease may help to prevent client and family from becoming discouraged. Care for neutropenic clients http://www. Retrieved June 29. December 17).com/od/leukemia/a/ Reassure client and family that the increased susceptibility to infection is only temporary.html http://lymphoma. RATIONALE: Client’s understanding may improve compliance and reduce risk factors. Sandy D.html http://www. RATIONALE: These precautions minimize client’s exposure to bacterial. (2013. from http://www. 9. Kathleen. March 6). from http://www.about. such as very hot. 2013. from http://emedicine. Nutrition. 2013. M. 2013. Use mouth care protocol (e. maybe only early signs of sepsis. IM injection) unless absolutely necessary. 3. (2010. RATIONALE: Explain the importance of good nutrition and vitamin and mineral supplementation. Refer to the oncology nurse specialist for further teaching and support. particularly Romito. 4. 2013.cancer. or highly acidic or spicy foods. urine. AMERICAN CANCER SOCIETY.htm http://emedicine.urmc. RATIONALE: Subtle changes in vital signs. from http://www.htm http://nihseniorhealth. diarrhea. very cold.cancer. Wolters Kluwer Health. rectal and vaginal examinations. ( National Cancer Institute. L. Retrieved June 13. Avoid invasive procedures (e. Record vital Golisano Children’s Hospital. March 7). Retrieved July blood and abnormal body secretions. RATIONALE: Certain procedures cause tissue trauma. Obtain cultures of sputum. January 18). oral=use toothettes) h. 2. (2012. viral and fungal pathogens. as ordered. 7. http://www. Instruct to avoid foods that may damage oral mucosa. May 20). from Wu.medscape. RATIONALE: Cultures can confirm infection and identify the causative National Cancer Institute.medscape. 8. 5. Notify physician of any change in vital signs. Lynda Juall (2009) Nursing Care Plans & Documentation: Nursing Diagnoses and Collaborative Problems. Explain reasons for precautions and restrictions. November 25).cfm . Allow time for questions and to verbalize fears. Retrieved June 29. Retrieved June 13. increasing the susceptibility of infection. 2013 from http://www.cancercenter. Retrieved July 13. (2008. both exogenous and endogenous. from Medscape: http://www.cancer.

com/leukemia/ .cfm http://www.cancercenter.cfm http://www.http://www.cfm http://www.cfm http://www.cancercenter.cfm http://www.prenhall.php http://www.pdf e/social-influence.cfm http://www.cfm