Ppt 17- Leukemia

Leukemia
⬗ The common feature of the leukemias is an unregulated proliferation or accumulation of white blood cells
(WBCs) in the bone marrow.
⬗ There is also proliferation in the liver and spleen and invasion of other organs, such as the meninges, lymph
nodes, gums, and skin. The leukemias are commonly classified according to the stem cell line involved, either
lymphoid or myeloid.
⬗ Leukemia is also classified as acute (abrupt onset) or chronic (evolves over months to years). Its cause is
unknown. There is some evidence that genetic influence and viral pathogenesis may be involved.
⬗ Bone marrow damage from radiation exposure or chemicals such as benzene and alkylating agents can also
cause leukemia.
Two major types
⬗ Lymphocytic (lymphoblastic) leukemias have cells from lymphoid pathways.
⬗ Myelocytic (myelogenous) leukemias have abnormal cells originating in myeloid pathways and have several
subtypes classed by cell characteristics; identifying the subtypes determines treatment options.

Clinical Manifestations
⬗ Cardinal signs and symptoms include weakness and fatigue, bleeding tendencies, petechiae and ecchymoses,
pain, headache, vomiting, fever, and infection.

Assessment
⬗ Obtain patient information about:
1. Age
2. Exposure to agents or ionizing radiation that increase the risk for leukemia
3. Recent history of frequent or severe infections (e.g., influenza, pneumonia, bronchitis) or unexplained fevers
4. A tendency to bruise or bleed easily or for a long period; platelet function is often decreased with leukemic
disorders
5. Weakness and fatigue
6. Associated symptoms (headaches, behavior changes, increased somnolence, decreased attention span,
lethargy, muscle weakness, loss of appetite, or weight loss)
⬗ Assess for and document:
1. Anemia and anemia-related symptoms
2. Neutropenia
3. Signs of infection, particularly in the respiratory, skin, and urinary systems
 Increased respiratory rate or dyspnea
 Abnormal breath sounds with cough
 Skin ulcer formation
 Urgent, frequent or painful urination
4. Skin changes from reduces perfusion
 Pallor and coolness to the touch
 Pale conjunctiva and palmar creases
 Bruising or petechiae
 Mouth sores that do not heal
5. GI changes from bleeding or decreased perfusion
 Nausea and anorexia
 Weight loss
 Rectal fissures
 Bloody stools
 Reduced bowel sounds, constipation
 Enlarged liver or spleen

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 Ppt 17- Leukemia
 Abdominal distension or tenderness
6. CNS changes from bleeding or reduced perfusion
 Cranial nerve dysfunction
 Papilledema
 Seizures or coma
7. Miscellaneous changes
 Bone and joint tenderness
 Lymph node enlargement
8. Psychosocial issues and concerns, especially anxiety and fear about the diagnosis, treatment, and outcome.
9. Abnormal CBC, including:
 Decreased hemoglobin and hematocrit levels
 Low platelet count
 WBC count (low, normal, or elevated) and differential
⬗ Diagnosis of leukemia is based on findings from a bone marrow biopsy. The leukemia type is diagnosed by cell
surface antigens and chromosomal or gene markers.

Planning and implementation

DRUG THERAPY FOR ACUTE LEUKEMIA
1. Induction therapy consists of combination chemotherapy started at the time of diagnosis.
– Neutropenia is a common side effect of induction therapy. Prolonged hospitalizations of 2 to 3 weeks
are common until recovery of bone marrow function occurs.
– Other side effects from drugs used for induction therapy include nausea, vomiting, diarrhea, alopecia,
stomatitis, kidney toxicity, liver toxicity, and cardiac toxicity.
2. Consolidation therapy consists of another course of either the same drugs used for induction at a different
dosage or a different combination of chemotherapy drugs.
– Consolidation therapy may be either a single course of chemotherapy or repeated courses.
3. Hematopoietic stem cell transplantation also may be considered, depending on the disease subtype and the
patient’s response to induction therapy.
4. Maintenance therapy may be prescribed for months to years after successful induction and consolidation
therapies for acute lymphocytic leukemia (ALL) and acute promyelocytic leukemia (APL).
– The purpose is to maintain the remission. Not all types of leukemia respond to maintenance therapy.

DRUG THERAPY FOR CHRONIC LEUKEMIA

⬗ The decision to initiate therapy is based on cytogenetic testing, disease stage, manifestations and disease
activity.
⬗ Imatinib mesylate (Gleevec) is used for chronic myelogenous leukemia (CML) that is Philadelphia chromosome
positive.
⬗ For patients with resistant CML or who are intolerant to Imatinib, Dasatinib (Sprycel) or Rituximab (Rituxan) are
used.
⬗ Rituximab is often combined with standard chemotherapy drugs or used as a single agent for patients with
chronic lymphocytic leukemia (CLL).
⬗ Hematopoietic stem cell transplantation is an option for patients with CLL.

REDUCING RISK FOR INFECTION

⬗ Potential for infection is related to decreased immune response and chemotherapy.
⬗ Infection is a major cause of death in the patient with leukemia because the WBCs are immature and cannot
function or the cells are depleted from chemotherapy.
⬗ Infection occurs through autocontamination (normal flora overgrows and penetrates the internal environment)
and cross-contamination (organisms from another person or the environment are transmitted to the patient).

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 Ppt 17- Leukemia
⬗ The three most common sites of infection are the skin, respiratory tract and intestinal tract.
⬗ Implement infection control and patient protection measures.
1. Wear a mask when entering the patient’s room if there is a chance of transmitting an upper respiratory
tract infection.
2. Observe strict aseptic procedures when performing dressing changes.
3. Place the patient in a private room, if possible.
4. Reduce environmental sources of contamination.
a. Do not leave standing collections of water in vases, denture cups, or humidifiers in the patient’s
room.
b. Use a minimal bacteria diet (no raw fruits and vegetables, undercooked meat, pepper or paprika)
c. Use high-deficiency particulate air (HEPA) filtration or laminar airflow syst.
5. Monitor for infection.
a. Monitor the daily CBC with differential WBC count and absolute neutrophil count (ANC).
b. Inspect the skin and mouth during every shift for lesions and breakdown.
c. Assess the lungs every 8 hours for crackles, wheezes, or reduced breath sounds.
d. Assess all urine for odor and cloudiness and ask the patient about any urgency, burning, or pain
present with urination.
e. Take vital signs, including temperature, at least every 4 hours.
f. Provide intervention to maintain skin integrity.
g. Implement agency neutropenia protocols when infection is suspected.
h. Drug therapy for infection may include antibiotic, antiviral or antifungal.

REDUCING RISK FOR INJURY

⬗ Potential for injury is related to bleeding and adverse drug reactions from chemotherapy.
⬗ Thrombocytopenia increases the risk of excessive bleeding and occurs from both leukemia and chemotherapy.
⬗ Institute precautions for patients with thrombocytopenia
⬗ Administer chemotherapy using best practices and monitor patient response.

DECREASING FATIGUE
– Fatigue is related to decreased tissue oxygenation and increased energy demands.
– Production of RBC is limited in leukemia, causing anemia that contributes to fatigue.
1. Collaborate with nutritionist to provide small, frequent meals high in protein and carbohydrates.
2. Administer transfusion therapy (e.g packed RBC, platelets or clotting factors)
3. Evaluate the patient’s response to drug therapy with hematopoietic growth factors such as:
a. Darbepoetin alfa (Aranesp) and epoetin alfa (Epogen and Procrit) to increase RBCs.
b. Oprelvekin (Neumega) to increase the production of platelets.
4. Eliminate or postpone activities that do not have a direct positive effect on the patient’s condition.

Community-based care
– Teach the patient and family about:
1. Measures to prevent infection.
2. The importance of continuing therapy and medical follow-up.
3. The need to report manifestations of infection or bleeding immediately to the health care provider.
4. Assessing for petechiae, avoiding trauma and sharp objects, applying pressure to wounds for 10 minutes, and
reporting blood in the stool or urine or headache that does not respond to acetaminophen.
5. Resources for psychological and financial support and for role and self-esteem adjustment.
6. Care of the central catheter if in place at discharge.
⬗ Assess the patient’s need for a home care nurse, aide, or equipment.