MANAGEMENT

OF PATIENTS
WITH
HEMATOLOGIC
NEOPLASMS

LECTURER: ROSELLE JOY C. BALAQUIT, RN

LEUKOCYTOSIS
•Increased level of WBCs in circulation
•Typically only one specific cell type is
increased
•Can be a normal response to need
•Prolonged or progressively increased
elevation in WBCs could indicate leukemia

LECTURER: ROSELLE JOY C. BALAQUIT, RN

 Common feature of Leukemias

• Unregulated proliferation of leukocytes in the bone

marrow
• Leaves little room for normal cell production
• Can be accompanied by a proliferation of cells in the
liver and spleen
• Can also be an infiltration of leukemic cells in other
organs
- meninges, lymph nodes, gums, & skin
LECTURER: ROSELLE JOY C. BALAQUIT, RN
 Classification of leukemia

•Classified according to the stem cell line

involved
1) Lymphoid-produce lymphocytes
2) Myeloid-produce non-lymphoid blood cells
•Classified as either acute or chromic

LECTURER: ROSELLE JOY C. BALAQUIT, RN

 Leukemia
•Hematopoietic malignancy with unregulated
proliferation of leukocytes
•Types:
1) Acute myeloid leukemia
2) Chronic myeloid leukemia
3) Acute lymphocytic leukemia
4) Chronic lymphocytic leukemia
•Each type has a different treatment and prognosis
LECTURER: ROSELLE JOY C. BALAQUIT, RN
 Classification by Cells Involved
• Leukemia: Proliferation of particular cell type:
Granulocytes
Lymphocytes
Infrequently erythrocytes or megakaryocytes
• Lymphoma: Neoplasms of lymphoid tissue, usually
derived from B lymphocyte
• Multiple myeloma: Malignancy of the most mature
form of B lymphocyte—the plasma cell
LECTURER: ROSELLE JOY C. BALAQUIT, RN
Acute leukemia
•Abrupt onset
•Leukocyte development is halted at the blast
phase
•Most leukocytes are undifferentiated cells or
blasts
•Progresses rapidly
•Death within weeks to months without
aggressive treatment
LECTURER: ROSELLE JOY C. BALAQUIT, RN
Chronic leukemia

•Evolves over a period of months to years

•Majority of leukocytes produced are mature
•No rush to treatment
•Careful monitoring
•People can live for years with it

LECTURER: ROSELLE JOY C. BALAQUIT, RN

 Myeloid
Leukemias
LECTURER: ROSELLE JOY C. BALAQUIT, RN
 Acute Myeloid
Leukemia
• Defect in stem cell that differentiate
into all myeloid cells: monocytes,
granulocytes, erythrocytes, and
platelets
• Most common nonlymphocytic leukemia
• Affects all ages with peak incidence at
age 67 years
• Prognosis is highly variable
• Manifestations: fever and infection,
weakness and fatigue, bleeding
tendencies, pain from enlarged liver or
spleen, hyperplasia of gums, bone pain
LECTURER: ROSELLE JOY C. BALAQUIT, RN
•Treatment:
 Aggressive chemotherapy—induction therapy,
 Hematopoietic stem cell transplantation
(HSCT)

•Supportive care
 May be the only option
 Antimicrobial therapy and transfusions
 Death occurs within months
LECTURER: ROSELLE JOY C. BALAQUIT, RN
 Chronic Myeloid Leukemia
(CML)
• Mutation in myeloid stem cell with uncontrolled proliferation of cells—
Philadelphia chromosome
• Stages: chronic phase, transformational phase, blast crisis
• Uncommon in people younger than age 20 years, with increased incidence with
age; mean age: 64 years
• Manifestations: initially may be asymptomatic, malaise, anorexia, weight loss,
confusion or shortness of breath caused by leukostasis, enlarged tender spleen,
or enlarged liver
• Treatment: imatinib mesylate (Gleevec) blocks signals in leukemic cells that
express BCR-ABL protein; chemotherapy, HSCT

LECTURER: ROSELLE JOY C. BALAQUIT, RN

Lymphocytic
Leukemias
LECTURER: ROSELLE JOY C. BALAQUIT, RN
 Acute Lymphocytic Leukemia (ALL)
• Uncontrolled proliferation of immature cells from lymphoid stem cell-
either B or T cells
• Most common in young children, boys more often than girls, peak
age 4 years old
• Prognosis is good for children; 85% for 3-year event-free survival but
drops with increased age <45% adults
• Manifestations: Pain from enlarged liver/spleen, bone, CNS;
headache and vomiting
• Treatment: chemotherapy, HSCT, monoclonal antibody therapy,
corticosteroids
LECTURER: ROSELLE JOY C. BALAQUIT, RN
 Chronic Lymphocytic Leukemia (CLL)
• Common malignancy of older adults, and the most prevalent
type of adult leukemia, mean: 72 years old
• Derived from a malignant clone of B lymphocytes
• Survival varies from 2 to 14 years depending on stage
• Manifestations: “B symptoms,” a constellation of symptoms
including fevers, drenching sweats (especially at night), and
unintentional weight loss
• Treatment: early stage “watch and wait”, chemotherapy,
monoclonal antibody therapy, IVIG for recurrent infections,
and HSCT
LECTURER: ROSELLE JOY C. BALAQUIT, RN
CARE OF
THE
PATIENT

LECTURER: ROSELLE JOY C. BALAQUIT, RN

Nursing Process: The Care of the Patient With
Leukemia—Assessment
• Health history
• Assess symptoms of leukemia and for complications
Anemia, infection, and bleeding
Weakness and fatigue
• Laboratory tests:
Leukocyte count, ANC, hematocrit, platelets,
creatinine and electrolyte levels, and coagulation and
hepatic function tests
Cultures as needed LECTURER: ROSELLE JOY C. BALAQUIT, RN
Nursing Process: The Care of the Patient
With Leukemia—Diagnoses
•Risk for infection and/or bleeding
•Impaired oral mucous membrane
•Imbalanced nutrition and fluid volume
•Acute pain
•Fatigue and activity intolerance
•Risk for imbalanced fluid volume
•Self-care deficits due to fatigue
•Anxiety
•Risk for spiritual distress and knowledge deficit
LECTURER: ROSELLE JOY C. BALAQUIT, RN
Collaborative Problems and Potential
Complications
• Infection
• Bleeding/DIC
• Renal dysfunction
• Tumor lysis syndrome

LECTURER: ROSELLE JOY C. BALAQUIT, RN

Nursing Process: The Care of the Patient With
Leukemia—Planning
Major goals may include:
 Absence of complications and pain
 Attainment and maintenance of adequate nutrition
 Activity tolerance
 Ability to provide self-care and to cope with the
diagnosis and prognosis
 Positive body image
 Understanding of the disease process and its
treatment
LECTURER: ROSELLE JOY C. BALAQUIT, RN
 Nursing Process: The Care of the Patient
With Leukemia—Interventions
• Interventions related to risk of
infection and bleeding
• Mucositis
Frequent, gentle oral hygiene
Soft toothbrush or if counts are
low, sponge-tipped applicators
Rinse only with NS, NS and
baking soda, or prescribed
solutions
Perineal and rectal care
LECTURER: ROSELLE JOY C. BALAQUIT, RN
• Improve nutritional intake
Oral care before and after meals
Administer analgesics before
meals
Appropriate treatment of
nausea
Small, frequent feedings
Soft foods that are moderate in
temperature
Low-microbial diet
Nutritional supplements
• Easing pain and discomfort • Maintaining fluid and electrolyte
Acetaminophen (Tylenol) balance
for fever and myalgias Intake and output, daily
Cool water sponging weights
Frequent bedding changes Assess for dehydration and
Gentle massage overload
Relaxation techniques Laboratory studies including
electrolytes, blood urea
• Decreasing fatigue and activity nitrogen, creatinine, and
intolerance hematocrit
Balance activity and rest Replacement as necessary
• Improve self-care, self-esteem,
anxiety, and grief with empathetic
listening and realistic reassurance
LECTURER: ROSELLE JOY C. BALAQUIT, RN
Lymphoma
• Neoplasm of lymphoid origin
• Usually start in lymph nodes but can involve lymphoid
tissue in the spleen, GI tract, liver, or bone marrow
• Classified according to degree of cell differentiation
and origin of predominant malignant cell
• Two major categories:
Hodgkin lymphoma
Non-Hodgkin lymphoma

LECTURER: ROSELLE JOY C. BALAQUIT, RN

 Non-Hodgkin Lymphoma (NHL)
• Lymphoid tissues become infiltrated with malignant cells; spread is
unpredictable and localized disease is rare
• Increases with age, with average age being 66 years
• Increased in autoimmune, prior treatment for cancer, organ
transplant, viral infections, exposure to pesticides
• Manifestation: lymphadenopathy, B symptoms, and symptoms
associated with lymphomatous masses
• Treatment is determined by type and stage of disease and may
include interferon, chemotherapy, radiation therapy, and HSCT

LECTURER: ROSELLE JOY C. BALAQUIT, RN

 Hodgkin Disease
• Relatively rare malignancy that has a high cure rate
• Suspected viral etiology, familial pattern, incidence in early 20s
and again after the age of 50 years; more common in men
• Unicentric; initiates in a single node
• Reed--Sternberg cell
• Manifestations: painless lymph node enlargement; pruritus; B
symptoms: fever, sweats, weight loss
• Treatment is determined by stage of the disease and may
include chemotherapy, radiation therapy, or both, and HSCT
for advanced disease
LECTURER: ROSELLE JOY C. BALAQUIT, RN
 Multiple Myeloma
• Malignant disease of the most mature form of B
lymphocyte—the plasma cell
• Plasma cells are large lymphocytes
• Originate in the bone marrow & arise from B cell
differentiation
• Result from T cell-dependent activation of B cells, however
they can also result from T cell-independent activation of
B cells
• Capable of secreting large volumes of antibodies
LECTURER: ROSELLE JOY C. BALAQUIT, RN
•Incidence increases with age; median 70 years old; 5
year survival rate; no cure
•Manifestations: bone pain reported in 80%, mostly
back and ribs; osteoporosis and fractures related to
bone destruction; hypercalcemia, renal impairment
and failure, anemia
•Treatment may include HSCT, chemotherapy,
corticosteroids, radiation therapy,
•New drugs being used: immunomodulatory drugs
(IMiDs), thalidomide analogs, monoclonal antibody

LECTURER: ROSELLE JOY C. BALAQUIT, RN

Multiple Myeloma Treatment
• Treatment may include:
Auto HSCT
Chemotherapy and radiation
Corticosteroid
• New drugs being used:
Immunomodulatory drugs (IMiDs)
Thalidomide analogs
Monoclonal antibody
LECTURER: ROSELLE JOY C. BALAQUIT, RN