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The term leukemia describes a malignant disorder of the blood and lymphforming tissues of the body. The bloods cellular components originate
primarily in the marrow of bones such as the sternum, iliac crest, and
cranium. All blood cells begin as immature cells (blasts or stem cells) that
differentiate and mature into RBCs, platelets, and various types of WBCs. In
leukemia, many immature or ineffective WBCs crowd out the developing
normal cells. As the normal cells are replaced by leukemic cells, anemia,
neutropenia, and thrombocytopenia occur.
Leukemia is acute when WBCs proliferate so rapidly that they lose the ability
to regulate cell division and do not differentiate into mature cells. In
the chronic forms of leukemia, the disease develops gradually. The type of
leukemia is based on the predominant cell line that is affected. In adults, the
most common of the acute leukemias is acute myelocytic leukemia, which
affects any type of WBC other than lymphocytes. The most common of the
chronic leukemias is chronic lymphocytic leukemia, which is characterized by
an abnormal increase in lymphocytes.
Current treatments include chemotherapy, biologic therapy (e.g., monoclonal
antibodies or interferon), radiation therapy, or transplantation (bone marrow
transplant, peripheral stem cell transplant, or umbilical cord blood
transplant).
Care Setting
Acute inpatient care on medical or oncology unit for initial evaluation and
treatment typically 46 weeks, and then at the community level.
Related Concerns
Cancer
Psychosocial aspects of care
Transplantation: postoperative and lifelong needs
Client Assessment Database
Data depend on degree/duration of the disease and other organ
involvement.
Activity/Rest
WBC: May be more than 50,000/cm with increased immature WBCs (shift to
left). Leukemic blast cells may be present.
Prothrombin time (PT)/activated partial thromboplastin
time (aPTT): May be prolonged. (Disseminated intravascular coagulation
[DIC] may occur with acute myelogenous leukemia, but it is especially
common in acute promyelocytic leukemia.)
LDH: May be elevated.
Serum/urine uric acid: May be elevated.
Bence Jones protein (urine): May be increased.
Bone marrow biopsy: Abnormal WBCs usually make up 50% or more of the
WBCs in the bone marrow. Often 60%90% of the cells are blast cells, with
erythroid precursors, mature cells, and megakaryocytes reduced.
Chest radiograph and lymph node biopsies: May indicate degree of
involvement.
Lumbar puncture: May find leukemic cells in cerebrospinal fluid (CSF)
Cytogenetics: Examination of chromosome abnormalities from samples of
peripheral blood, bone marrow, or lymph nodes that may indicate prognostic
features.
Nursing Priorities
1. Prevent infection during acute phases of disease/treatment.
2. Maintain circulating blood volume.
3. Alleviate pain.
4. Promote optimal physical functioning.
5. Provide psychologic support.
6. Provide information about disease process/prognosis and treatment needs.
Discharge Goals
1. Complications prevented/minimized.
2. Pain relieved/controlled.
ACTIONS/INTERV RATIONALE
ENTIONS
1.
Protect client from
Infection
potential sources of
pathogens/infection.Note: Profo
Protection (NIC) und bone marrow suppression,
neutropenia, and
Independent
chemotherapy place client at
great risk for infection.
1.
Place in
2.
Prevents crossprivate room.
contamination/reduces risk of
Screen/limit
infection.
visitors as
3.
Although fever may
indicated. Prohibit accompany some forms of
use of live
chemotherapy, progressive
plants/cut flowers. hyperthermia occurs in some
Restrict fresh fruits types of infections, and fever
and vegetables or (unrelated to drugs or blood
make sure they are products) occurs in most
washed or peeled. leukemia
2.
Require good clients. Note:Septicemia may
hand-washing
occur without fever.
protocol for all
4.
Helps reduce fever,
personnel and
which contributes to fluid
visitors.
imbalance, discomfort, and
3.
Monitor
CNS complications.
temperature. Note 5.
Prevents stasis of
correlation
respiratory secretions,
between
reducing risk of
temperature
atelectasis/pneumonia.
elevations and
6.
Early intervention is
chemotherapy
essential
to prevent
treatments.
Observe for fever sepsis/septicemia in
immunosuppressed person.
associated with
7.
Prevents sheet burn/skin
tachycardia,
excoriation.
hypotension,
subtle mental
8.
May indicate local
changes.
infection.Note: Open wounds
may not produce pus because
4.
Prevent
of insufficient number of
chilling. Force
fluids, administer granulocytes.
tepid sponge bath. 9.
The oral cavity is an
excellent
medium for growth of
5.
Encourage
organisms and is susceptible to
frequent turning
ulceration and bleeding.
and deep
breathing.
10. Promotes cleanliness,
reducing risk of perianal
6.
Auscultate
breath sounds,
noting crackles,
rhonchi; inspect
secretions for
changes in
characteristics;
e.g., increased
sputum production
or change in
sputum color.
Observe urine for
signs of infection;
e.g., cloudy, foulsmelling, or
presence of
urgency or burning
with voids.
7.
Handle client
gently. Keep linens
dry/wrinkle free.
8.
Inspect skin
for tender,
erythematous
areas; open
wounds. Cleanse
skin with
antibacterial
solutions.
9.
Inspect oral
mucous
membranes.
Provide good oral
hygiene. Use a soft
toothbrush,
sponge, or swabs
for frequent mouth
care.
10. Promote
good perianal
hygiene. Examine
perianal area at
least daily during
acute illness.
Provide sitz baths,
using Betadine or
Hibiclens if
indicated. Avoid
rectal
temperatures, use
of suppositories.
11. Coordinate
procedures and
tests to allow for
uninterrupted rest
periods.
12. Encourage
increased intake of
foods high in
protein and fluids
with adequate
fiber.
1.
Avoid/limit
invasive
procedures (e.g.,
venipuncture and
injections) as
possible.
1.
Break in skin could
provide an entry for
pathogenic/potentially lethal
organisms. Use of central
venous lines (e.g., tunneled
catheter or implanted port) can
effectively reduce need for
Collaborative
frequent invasive procedures
and risk of
1.
Monitor
infection. Note:Myelosuppressi
laboratory studies, on may be cumulative in
e.g.:
nature, especially when
2.
CBC, noting multiple drug therapy
(including steroids) is
whether WBC
prescribed.
count falls or
sudden changes
Decreased numbers of
occur in
normal/mature WBCs can
neutrophils;
3.
Grams stain result from the disease process
cultures/sensitivity. or chemotherapy,
compromising the immune
4.
Review serial response and increasing risk of
chest x-rays.
infection.
5.
Prepare
for/assist with
1.
Verifies presence of
leukemia-specific infections; identifies specific
treatments such as organisms and appropriate
chemotherapy,
therapy.
radiation, and/or
bone marrow
2.
Indicator of
transplant.
development/resolution of
respiratory complications.
6.
Administer
medications as
3.
Leukemia is usually
indicated, e.g.:
treated with a combination of
antibiotics;
these agents, each requiring
specific safety precautions for
7.
Colonystimulating factors client and care providers.
(CSFs): e.g.,
4.
May be given
sargramostim
prophylactically or to treat
(Leukine),
specific infection.
filgrastim
5.
Restores WBCs destroyed
(Neupogen),
by chemotherapy and reduces
pegfilgrastim
risk of severe infection and
(Neulasta).
death in certain types of
8.
Avoid use of leukemia.
aspirin-containing 6.
Aspirin can cause gastric
antipyretics.
bleeding and further decrease
9.
Provide
platelet count.
nutritious diet, high 7.
Proper nutrition
in protein and
enhances immune system.
calories, avoiding Minimizes potential sources of
raw fruits,
bacterial contamination.
vegetables, or
uncooked meats.
NURSING DIAGNOSIS: risk for deficient Fluid Volume
Risk factors may include
Excessive losses; e.g., vomiting, hemorrhage, diarrhea
Decreased fluid intake; e.g., nausea, anorexia
Increased fluid need; e.g., hypermetabolic state, fever, predisposition for
kidney stone formation/tumor lysis syndrome
Possibly evidenced by
[Not applicable; presence of signs and symptoms establishes
an actual diagnosis.]
DESIRED OUTCOMES/EVALUATION CRITERIACLIENT WILL:
Hydration (NOC)
Demonstrate adequate fluid volume, as evidenced by stable vital signs;
palpable pulses; urine output, specific gravity, and pH within normal limits.
Risk Control (NOC)
Identify individual risk factors and appropriate interventions.
Initiate behaviors/lifestyle changes to prevent development of dehydration.
ACTIONS/INTERVE RATIONALE
NTIONS
1.
Tumor lysis
Fluid
syndrome occurs when
Management
destroyed cancer cells
(NIC)
release toxic levels of
potassium, phosphorus,
Independent
and uric acid. Elevated
phosphorus and uric acid
1.
Monitor I&O. levels can cause crystal
Calculate insensible formation in the renal
losses and fluid
tubules, impairing
balance. Note
filtration and leading to
decreased urine
renal failure.
output in presence 2.
Measure of
of adequate intake. adequacy of fluid
Measure urine
replacement and kidney
specific gravity and function. Continued
pH.
intake greater than
2.
Weigh daily. output may indicate
renal insult/obstruction.
3.
Monitor BP
and HR.
3.
Changes may
4.
Evaluate skin reflect effects of
hypovolemia
turgor, capillary
(bleeding/dehydration).
refill, and general
condition of mucous 4.
Indirect indicators
membranes.
of fluid status/hydration.
5.
Note presence 5.
Affects intake, fluid
of nausea, fever.
needs, and route of
replacement.
6.
Encourage
fluids of up to 34 6.
Promotes urine
L/day when oral
flow, prevents uric acid
intake is resumed.
precipitation, and
enhances clearance of
antineoplastic drugs.
1.
Suppression of
Bleeding
bone marrow and
Precautions (NIC) platelet production
places client at risk for
1.
Inspect
spontaneous/uncontrolle
skin/mucous
d bleeding.
membranes for
2.
Fragile tissues and
petechiae,
altered clotting
ecchymotic areas; mechanisms increase the
note bleeding
risk of hemorrhage
gums, frank or
following even minor
occult blood in
trauma.
stools and urine,
3.
When bleeding is
oozing from
present, even gentle
invasive line sites. brushing may cause
2.
Implement
more tissue damage.
measures to
Alcohol has a drying
prevent tissue
effect and may be
injury/bleeding;
painful to irritated
e.g., gentle
tissues.
brushing of teeth or 4.
May help reduce
gums with soft
gum irritation.
toothbrush, cotton
5.
Maintains
swab, or spongefluid/electrolyte balance
tipped applicator;
using electric razor in the absence of oral
intake; prevents or
instead of sharp
minimizes tumor lysis
razors when
syndrome, reduces risk
shaving; avoiding
of renal complications.
forceful nose
6.
Relieves
blowing and
needlesticks when nausea/vomiting
associated with
possible; using
sustained pressure administration of
chemotherapy agents.
(sandbags or
pressure dressings) 7.
Improves renal
on oozing
excretion of toxic
puncture/IV sites.
byproducts from
3.
Limit oral care breakdown of leukemia
cells. Reduces the
to mouth rinse if
chances of nephropathy
indicated (e.g., a
mixture of 1/4 tsp as a result of uric acid
Hb/Hct, clotting.
9.
Administer
RBCs, platelets,
clotting factors.
10. Maintain
external central
vascular access
device (subclavian
or tunneled
catheter or
implanted port).
11. Administer
medications, e.g.:
12. Stool
softeners;
13. Oral
contraceptives.
NURSING DIAGNOSIS: acute Pain
May be related to
Physical agents; e.g., enlarged organs/lymph nodes, bone marrow packed
with leukemic cells
Chemical agents; e.g., antileukemic treatments
Psychologic manifestations; e.g., anxiety, fear
Possibly evidenced by
Reports of pain (bone, nerve, headaches, and so forth)
Guarding/distraction behaviors, facial grimacing, alteration in muscle tone
Autonomic responses
DESIRED OUTCOMES/EVALUATION CRITERIACLIENT WILL:
Pain Level (NOC)
Report pain is relieved/controlled.
Appear relaxed and able to sleep/rest appropriately
ACTIONS/INTERVEN
TIONS
Pain Management
(NIC)
Independent
1.
Investigate
reports of pain. Note
changes in degree
(use scale of 010)
and site.
2.
Monitor vital
signs, note nonverbal
cues; e.g., muscle
tension, restlessness.
3.
Provide quiet
environment and
reduce stressful
stimuli; e.g., noise,
lighting, constant
interruptions.
4.
Place in position
of comfort and
support joints,
extremities with
pillows/padding.
5.
Reposition
periodically and
provide/assist with
gentle ROM exercises.
6.
Provide comfort
measures (e.g.,
massage, cool packs)
and psychologic
support (e.g.,
encouragement,
presence).
7.
Review/promote
clients own comfort
interventions; e.g.,
RATIONALE
1.
Helpful in
assessing need for
intervention; may
indicate developing
complications.
2.
May be useful in
evaluating verbal
comments and
effectiveness of
interventions.
3.
Promotes rest
and enhances coping
abilities.
4.
May decrease
associated bone/joint
discomfort.
5.
Improves tissue
circulation and joint
mobility.
6.
Minimizes need
for/enhances effects of
medication.
7.
Successful
management of pain
requires client
involvement. Use of
effective techniques
provides positive
reinforcement,
promotes sense of
control, and prepares
client for interventions
to be used after
discharge.
8.
Using own
learned
perceptions/behaviors
to manage pain can
help client cope more
effectively.
position, physical
activity/nonactivity.
8.
Evaluate and
support clients
coping mechanisms.
9.
Encourage use
of stress management
9.
Facilitates
relaxation, augments
pharmacologic
therapy, and enhances
coping abilities.
10. Helps with pain
management by
redirecting attention.
techniques; e.g.,
11. Rapid turnover
relaxation/deepand destruction of
breathing exercises, leukemic cells during
guided imagery,
chemotherapy can
visualization,
elevate uric acid,
therapeutic touch.
causing swollen
painful joints in some
1.
Assist
clients. Note:Massive
with/provide
infiltration of WBCs
diversional activities, into joints can also
relaxation techniques. result in intense pain.
12. Given for mild
Collaborative
pain not relieved by
comfort
1.
Monitor uric
measures. Note: Avoid
acid level as
aspirin-containing
appropriate.
products because they
2.
Administer
may potentiate
medications as
hemorrhage.
indicated:
13. Use around-the3.
Analgesics; e.g., clock, rather than prn,
acetaminophen
when pain is
(Tylenol);
severe. Note: Use of
patient-controlled
4.
Opioids; e.g.,
analgesia (PCA) is
codeine, morphine,
beneficial in
hydromorphone
preventing peaks and
(Dilaudid);
valleys associated with
5.
Antianxiety
intermittent drug
agents; e.g.,
administration and
diazepam (Valium),
increases clients
lorazepam (Ativan).
sense of control.
14. May be given to
enhance the action of
analgesics/opioids.
ACTIONS/INTERVENT RATIONALE
IONS
1.
Effects of
Energy Management leukemia, anemia, and
(NIC)
chemotherapy may be
cumulative (especially
Independent
during acute and
active treatment
1.
Evaluate reports phase), necessitating
of fatigue, noting
assistance.
inability to participate 2.
Helps client
in activities or ADLs.
prioritize activities and
2.
Encourage client arrange them around
to keep a diary of daily fatigue pattern.
routines and energy
3.
Restores energy
Collaborative
1.
Provide
supplemental oxygen.
Statement of misconception
DESIRED OUTCOMES/EVALUATION CRITERIACLIENT WILL:
Knowledge: Illness Care (NOC)
Verbalize understanding of condition/disease process and potential
complications.
Verbalize understanding of therapeutic needs.
Initiate necessary lifestyle changes.
Participate in treatment regimen.
ACTIONS/INTERVENTI RATIONALE
ONS
1.
Treatments can
Teaching: Disease
include various
Process (NIC)
antineoplastic drugs,
transfusions,
Independent
peripheral progenitor
(stem) cell
1.
Review pathology transplant or bone
of specific form of
marrow transplant.
leukemia and various
treatment options.