NURSING CARE

IN PATIENTS WITH LEUKEMIA

A. DEFINITIONS

Leukemia is acute or chronic neoplasm of blood-

forming cells in the bone marrow and lymph pulse
(Reeves, 2001). Characteristic of leukemia is irregular
proliferation or accumulation of white blood ssel
sumusm bone, replacing the normal bone marrow
elements. Also been a proliferation in the liver, spleen
and lymph nodes, and invasion of non-haematological
organs, such as the meninges, gastrointesinal tract,
kidneys and skin.
B. Etiology

The exact cause is unknown, but there are predisposing factors that
cause leukemia are:
1. Genetic factors: specific virus causes a change in the structure of
the gene (T cell leukemia-lymphoma virus / HTLV)
2. Ionizing radiation: work environment, prenatal, previous cancer
treatment
3. Exposure to chemicals such as benzene, arsenic, chloramphenicol,
phenylbutazone, and anti-neoplastic agents.
4. Immunosuppressive medications, such as carcinogenic drug
diethylstilbestrol
5. Hereditary factors, for example in monozygotic twins
6. Chromosomal abnormalities: Bloom's syndrome, trisomy 21
(Down's syndrome), Trisomy G (Klinefelter's syndrome), Fanconi's
syndrome, Philadelphia chromosome positive, Telangiektasis
ataxia.
C. Types of leukemia

1. Mielogenus Acute Leukemia

AML stem cells hematopeotik about that later
differentiate into all myeloid cells: monocytes,
granulocytes, erythrocytes, erythrocytes and platelets.
All age groups can be affected; incidence increases
with age. Nonlimfositik leukemia is the most common.

2. Mielogenus Chronic Leukemia

CML is also included in the system stem cell myeloid
malignancies. But more than the acute form of normal
cells, so the disease is milder. CML rarely attack people
under 20 years old. Manifestations similar to the
description of AML but milder signs and symptoms, the
patient shows no symptoms for many years, the
increase in leukocyte sometimes to an extraordinary
amount, enlarged spleen.
3. Acute lymphocytic Luekemia
ALL limfoblast considered a malignant
proliferation. Often occur in children, men more
than women, the peak incidence age of 4
years, after age 15 ALL rare. Manifestations of
immature lymphocytes proliferate in the bone
marrow and peripheral tissues, thereby
disrupting normal cell development ..

4. Chronic lymphocytic leukemia

CLL is a mild abnormalities of individuals aged
50 to 70 years. Clinical manifestations of
patients are asymptomatic, newly diagnosed
during a physical examination or treatment of
other diseases.
D. SIGNS AND SYMPTOMS
1. Activities: fatigue, weakness, malaise, muscle fatigue.
2. Circulation: palpitations, tachycardia, cardiac mur-mur, pale
mucous membranes.
3. Eliminsi: diarrhea, perianal tender, bright red blood, black
stools, decreased output of urine.
4. Integrity ego: a feeling of helplessness, withdrawn, fearful,
easily aroused, anxiety.
5. Food / liquids: anorexia, vomiting, changes in taste, pharyngitis,
weight loss and dysphagia
6. Neurosensori: decreased coordination, disorientation, dizziness,
numbness, paresthesia, seizure activity, muscle easily aroused.
7. Pain: abomen pain, headaches, joint pain, restless behavior
carefully
8. Respiratory: shortness of breath, cough, dyspnoea, takipneu,
ronkhi, rush, decreased breath sounds
9. Security: visual impairment, uncontrolled spontaneous bleeding,
fever, infection, redness, purpura, enlarged lymph nodes.
10. Sexuality: changes in libido, menstrual changes, impotence,
menorrhagia.
F. DIAGNOSIS SUPPORT
1. A complete blood count: showing normocytic anemia
normocytic
2. Hemoglobulin: can less than 10 gr/100ml
3. Reticulocytes: number is usually low
4. Platelets: very low (<50000/mm)
5. SDP: probabaly more than 50000/cm with increasing SDP
immatur
6. PTT: elongated

7. LDH: possible increased

8. Serum uric acid: possible increased
9. Muramidase serum: acute monocytic leukemia binding to
and mielomonositik
10. Copper serum: increased
11. Serum zinc: decrease
12. Photos chest and biopsy lymph nodes: to indicate the
degree of involvement
G. MANAGEMENT
1. Implementation of chemotherapy
2. Cranial irradiation
3. There are three phases of implementation keoterapi:
a. Induction phase
Dimulasi 4-6 weeks after the diagnosis is established. In
this phase given kortikostreroid therapy (prednisone),
vincristine and L-asparaginase. Otherwise the induction
phase behasil if signs of disease is reduced or absent in
the bone marrow and found the number of young cells is
less than 5%.
b. Phase of the central nervous system prophylaxis
In this phase of therapy given methotrexate, cytarabine
and intrathecal hydrocotison through invsi preventing
leukemia cells to the brain. Cranial irradiation therapy is
performed only in patients with leukemia who experience
central nervous system disorders.
c. Consolidation
In this phase, the combination treatment done
remisis fatherly maintain and reduce the number of
leukemia cells circulating in the body. Periodically,
weekly or monthly full blood examination to assess
response to treatment of bone marrow. If there is
bone marrow suppression, then treatment is stopped
temporarily or reduced drug doses.
H. ASSESSMENT
1. Medical history: previous cancer treatment
2. Family history: a haematological disorder, the
presence of hereditary factors such as monozygotic
twins)
3. Assess for signs of anemia: weakness, fatigue,
pallor, headache, anorexia, vomiting, spasms,
breathing fast
4. Assess for signs of leukopenia: fever, stomatitis,
symptoms of upper respiratory infections, urinary
5. Assess for signs of thrombocytopenia: ptechiae,
purpura, mucous membrane bleeding, hematoma
formation, purpura; examined for signs of extra-
medullary invasion: lymphadenopathy,
hepatomegaly, splenomegaly.
6. Kaji testicular enlargement, hematuria,
hypertension, kidney failure, inflammation and pain in
the rectal sekkitar.

I. NURSING DIAGNOSIS AND INTERVENTION

1. High risk of infection with menururnnya
berhubungn secondary immune system maturation
disorder SDP, an increasing number of immature
lymphocytes, immunosuppression, bone marrow
peneknan.
Objective: patients free from infection
Expected outcomes:
a. Normotermia
b. Negative culture results
c. Improved healing
Intervention:
a. Place in a special room. Limit visitors as indicated.
b. Wash hands for all staff and visitors.
c. Awsi temperature, consider the relationship
between rising temperatures and chemotherapy
treatment. Observations with respect to fever,
tachycardia, hypotension, mental changes sketchy.
d. Prevent shivering: increase fluids, give bath
compress
e. Encourage frequent change of position, deep
breathing and coughing.
f. Auskultsi breath sounds, consider the rush, ronkhi;
inspection secretion to changes in characteristics,
sputum or sputum sample peningktatan thick, foul
odor to urine urinate suddenly or burning.
g. Inspection skin fatherly tenderness, area
erythematosus; open wound. Besihkan skin with
antibacterial solution.
h. Inspection of the oral mucous membranes. Clean
mouth with a soft toothbrush.
i. Increase perianal hygiene. Give soak sit when using
Betadine or Hibiclens diindiksikan.
j. Provide uninterrupted rest period
k. Encourage an increase in the input high-protein
foods and liquids.
l. Avoid invasive procedures (needle puncture and
injection) when possible.
m. Collaboration:
Supervise laboratory tests eg blood count lerngkap,
whether SDP down or sudden changes on neutrophils;
culture grams / sensitivity.
Review the chest photo series.
 Provide examples of antibiotic drugs as indicated.
Avoid antipyretics that contain aspirin.
Provide low-bacteria diet eg food cooked, processed
2. High risk of fluid volume deficits associated with
excessive loss: vomiting, bleeding, diarrhea, decreased
fluid intake: nausea, anorexia; increased fluid
requirements: fever, hypermetabolic
Objective: fluid volume are met
Expected outcomes:
a. Adequate fluid volume
b. Mucosa moist
c. Stable vital signs: BP 90/60 mm Hg, pulse 100 x /
min, RR 20 x / min
d. Palpable pulse
e. Urine output of 30 ml / h
f. Kapileri refill <2 seconds
Intervention:
a. Supervise the input / output of. Calculate the loss
of fluid and fluid keseimbangna. Note the decrease in
urine, measuring urine specific gravity and pH.
b. Measure your weight every day
c. Monitor BP and heart rate
d. Evaluation of skin turgor, capillary refill, and the
condition of the mucous membrane.
e. Give fluid intake 3-4 L / day
f. Inspection of skin / mucous membranes for
petechiae, ecchymoses area; notice bleeding gums,
blood or faint rust color in the stool and urine; further
bleeding from the puncture invsif.
g. Implement measures to prevent tissue injury /
bleeding.
h. Limit oral treatment for mouth wash when
indicated
i. Give soft diet.
Supervise laboratory tests: platelet count, hemoglobin
/ hematocrit, clotting.
Provide HR, platelets, clotting factors.
Maintain an external central vascular access devices
(arterial catheter subklavikula, tunneld, implantable
ports)
Provide medications as indicated: Ondansetron,
allopurinol, acetate or potassium acetate, sodium
biukarbonat, stool softeners.

3. Pain associated with physical agents such as organ

enlargement / lymph nodes, bone marrow cells are
packed with leukemia; chemical agent treatment
antileukemik
Objective: pain is resolved
Expected outcomes:
a. Patient states pain is lost or controlled
Intervention:
a. Assess pain, notice changes in the degree and side
(use a scale of 0-10)
b. Monitor vital signs, note the non-verbal clues eg
muscle tension, restlessness.
c. Provide quiet environment and reduce stressful
stimuli.
d. Put on comfortable and chock posis joints,
extremities with pillows.
e. Change position periodically and gentle range of
motion exercises help.
f. Provide comfort measures (massage, cold
compresses and psychological support)
g. The review / enhance patient comfort intervention
itself
h. Evaluation and support patients coping
mechanisms.
j. Bantu therapeutic activity, relaxation techniques.
k. Collaboration:
Monitor uric acid levels
Give him drugs as indicated: analgesics
(acetaminophen), narcotics (codeine, meperidine,
morphine, hydromorphone)
Agent antiansietas (diazepam, lorazepam)

4. Activity intolerance related to general weakness,

increased metabolic rate
Objective: patients were able to tolerate the activity
Expected outcomes:
a. Increased tolerance activity can be measured
b. Participate in daily activities appropriate level of
c. Showed a physiological sign of intolerance eg pulse,
respiration and BP within normal limits
Intervention:
d. Evaluation reports of weakness, watch
aktivitas.berikan inability to participate in a quiet
neighborhood and the rest period without ganggaun
e. Implement energy saving techniques, examples
better sitting than standing, use a chair to madi
f. Schedule ate about chemotherapy. Provide oral
hygiene before meals and give antiemetics as
indicated
g. Collaboration: give supplemental oxygen

5. Risk of bleeding associated with thrombocytopenia

Objective: patients were free of symptoms of bleeding
Expected outcomes:
a. TD 90/60mmHg
b. Nadi 100 x / min
c. Excretions and secretions negtif on blood
d. Ht 40-54% (men), 37-47% (permpuan)
g. Ask the patient to alert nurses when there is
seepage of blood from the gums
h. Inspection of the skin, mouth, nose, urine, feces,
vomit and a puncture IV to hemorrhage
i. Frequent intervals TV monitor and be aware of signs
of bleeding.
j. Use a small gauge needle
k. If there is bleeding, elevate the affected part and
give a cold compress and press gently.
l. Give cegh bearing beds for trauma
m. Instruct the patient to use a soft toothbrush or
electric shaver.
6. Changes in tissue perfusion related to interruption
of blood flow secondary destruction of human
existence
Objective: Adequate perfusion
Expected outcomes:
a. Input and output balanced
b. Urine output of 30 ml / h
c. Kapileri refill <2 seconds
d. Stable vital signs
e. Strong peripheral pulses palpable
f. Skin warm and no cyanosis
Intervention:
a. Monitor vital signs
b. Assess skin for the cold, pale, slowness capillary
refill
c. Note the change in level of consciousness
d. Maintain adequate fluid intake
e. Evaluation of edema
f. Collaboration:
Supervise laboratory; GDA, AST / ALT, CPK, BUN
serum electrolytes, provide a replacement as
indicated
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