LEUKEMIA
NEHA SRIVASTAVA
SENIOR NURSING TUTOR
PIPRAMS
ANATOMY OF BLOOD CELLS
ANATOMY OF BLOOD CELLS
These blood cells start as hematopoietic (hemo = blood, poiesis =
make) stem cells.
The stem cells develop into either myeloid cells or lymphoid
cells.
If blood cells were to continue to develop normally, the mature
forms of these cells are as follows:
ANATOMY OF BLOOD CELLS
1.Myeloid cells develop into red blood cells, platelets and
certain types of white blood cells
(basophils, eosinophil's and neutrophils).
2.Lymphoid cells develop into certain white blood cells
(lymphocytes and natural killer cells).
ANATOMY OF BLOOD CELLS
Mature, normal blood cells include:-
Red blood cells: Cells that carry oxygen and other vital
materials to all tissues and organs in your body.
White blood cells: Cells that fight infection.
Platelets: Cells that help your blood clot.
INTRODUCTION
Leukemia begins in bone marrow, the soft spongy tissue in the
inner cavity of your bones, where your body’s blood cells are
made. Blood cells go through multiple stages before reaching
their fully mature forms.
INTRODUCTION
Leukemia is a cancer of the blood, characterized by the rapid
growth of abnormal blood cells. This uncontrolled growth
takes place in your bone marrow, where most of your body’s
blood is made.
Leukemia cells are usually immature (still developing) white
blood cells.
DEFINITION
The term leukemia comes from the Greek words for “white”
(leukos) and “blood” (haima).
Leukemia is defined as uncontrolled neoplastic proliferation
of leucocyte precursors.
INCIDENCE
Leukemia is the most common malignancy of
children less than 15 years of age.
The peak incidence is at 4 years of age. Incidence in
males is greater than in females. It is twice more
common in white than black children.
ETIOLOGY
The exact cause of leukemia is unknown but several etiologic
factors have been identified including:-
Viruses like Human Papilloma Virus, Epstein-Barr Virus
Radiations
Exposure to chemicals and drugs like benzene and Dilantin
Familial predisposition
Chromosomal abnormalities
CLASSIFICATION
CLASSIFICATION
Leukemia can be classified according to predominant cell type
and level of cell maturity as:-
Lympho: It means leukemia involving the lymphoid series.
Myelo: It means leukemia of myeloid (bone marrow origin)
series.
Blastic: It involves immature cells.
Cytic: It involves mature cells.
PATHOPHYSIOLOGY
Fewer red blood cells, healthy white blood cells and platelets
are made and released into your blood. As a result, your body’s
organs and tissues won’t get the oxygen needed to work
properly. Also, your body won’t be able to fight infections or
form blood clots when needed.
PATHOPHYSIOLOGY
Leukemia is unrestricted, neoplastic proliferation of immature
white blood cells in blood forming tissues of the body.
The resultant pathology and clinical manifestations are caused
due to infiltration and replacement of any body tissue with non-
functional leukemic cells.
Abnormal immature leucocytes circulate in blood.
These immature cells do not directly attack or destroy normal
blood cells but destruction of normal cells occur due to
competition for nutrients.
PATHOPHYSIOLOGY
RETICULOENDOTHELIAL
SYSTEM(RES)
FUNCTION OF LYMPH NODES:-
Proper functioning of the immune system acting as filters as
foreign particles including-cancer cells, but have no
detoxication function.
It is a part of immune system and it filters substances that
travel through the lymphatic system fluid contain
lymphocytes that body fight against infection and diseases.
RETICULOENDOTHELIAL
SYSTEM(RES)
FUNCTION OF SPLEEN:-
It is responsible for storing and removing Of R.B.C from
the blood as well as antigen surveillance of the blood and
antibody production.
CLINICAL
MANIFESTATION
1. BONE MARROW DYSFUNCTION
In all types of leukemia, the proliferating cells depress bone
marrow production of formed elements of the blood by
competing for nutrients and depriving the normal cells of
essential nutrients required for cellular metabolism. The main
consequences of bone marrow dysfunction are:-
Anemia due to reduced RBCs
Infection due to neutropenia.
Bleeding tendencies due to reduced platelet counts
CONT……
The invasion of bone marrow with leukemic cells causes
weakening of bones and tendency towards fractures.
The most frequent presenting sign and symptoms of leukemia
occur due to infiltration of bone marrow. These features
include fever, pallor, fatigue, anorexia, hemorrhage, bone and
joint pain.
2. INFILTRATION INTO ORGANS
The blood forming organs like liver, spleen and lymph glands
demonstrate marked infiltration, enlargement and eventually
fibrosis.
3. HYPERMETABOLISM
The immense metabolic needs of proliferating leukemic cells
deprive all body cells of nutrients necessary for survival.
This results in muscle wasting, weight loss, anorexia and fatigue.
ACUTE LYMPHOID LEUKEMIA (ALL)
Acute lymphoid or acute lymphocytic leukemia is the most
commonly diagnosed cancer in children, which accounts for 80%
of all childhood leukemias.
Many etiologic factors have been implicated, that might increase
the risk of developing leukemia like viruses, irradiation, exposure
to certain toxic chemicals and drugs and a genetic predisposition.
Acute lymphocytic leukemia develops when lymphoid cell tine is
affected.
TYPES
i. T cell leukemia
It is seen is 10-15% cases of acute lymphocytic leukemia. It is
seen in older children, particularly males.
It has the following features:-
1.Mediastinal mass
2.Hepatospleenomegaly
3.High WBC Count
4.CNS involvement may be seen
5.Poor prognosis
TYPES
ii.B-cell leukemia -It is seen in 1-2% children with ALL. It is an
aggressive form and has poor prognosis.
iii.Pre-B cell -It has good prognosis and responds well to therapy.
iv.Null cell leukemia- It is the most common type of childhood
ALL, occurring in 75% cases. It has better prognosis than other
types.
ACUTE NON-LYMPHOID LEUKEMIA/ACUTE
MYELOID LEUKEMIA (AML)
Acute non-lymphocytic leukemia is abnormal proliferation of
monocytes and myelocytes in bone marrow.
It is present in approximately 15% children with leukemia.
It has a poor prognosis.
ACUTE NON-LYMPHOID LEUKEMIA/ACUTE
MYELOID LEUKEMIA (AML)
It includes the following subtypes:-
1.Acute myeloblastic leukemia
2.Acute promyelocytic leukemia
3.Acute myelomonocytic leukemia
4.Acute monocytic leukemia
5.Acute erythrocytic leukemia
CLINICAL FEATURES
The clinical features of AML are:
Recurrent chronic infections
Fatigue
Lymphadenopathy
Hepatospleenomegaly
Bone or joint pain
Pallor
CLINICAL FEATURES
Frequent bruising
Gingival hypertrophy may be present
Features of CNS involvement like headache, blurred vision,
fundal hemorrhage and paresis.
Other life threatening problems like slugging and clumping of
leukemic cells in small cerebral capillaries and hyperuricemia.
Thrombocytopenia is also present.
DIAGNOSTIC EVALUATION
Leukemia is usually suspected from history, physical
manifestations and peripheral blood smear that contains
immature leucocytes frequently combined with low normal
blood counts.
Diagnosis is confirmed by bone marrow examination. A
leukemic marrow is hypercellular, with 60-100% immature
white blood cells and reduction in normal marrow components.
A finding of more than 25% of abnormal lymplioblasts or
myeloblasts is diagnostic.
DIAGNOSTIC EVALUATION
Blood investigations reveal an elevated serum uric acid level due
to increased turnover of malignant cells.
Radiological studies are done to evaluate presence of
mediastinal mass.
Liver and renal function test are done to detect leukemic cells
infiltration in liver and kidneys.
Lumbar puncture is done to assess CNS involvement.
Cytomorphologic, cytochemical and immunologic studies to
categorize the disease into sub groups.
MANAGEMENT
Treatment of leukemia involves systemic chemotherapy with or
without cranial irradiation.
A. Chemotherapy: It is given in three phases:-
1.Induction phase
2.Consolidation phase
3.Maintenance therapy
4.Bone marrow transplantation
INDUCTION PHASE
This is the phase that reduces leukemic cells to an undetectable
level, a state known as remission.
In remission, there is no evidence of leukemia on physical
examination, bone marrow evaluation, peripheral blood smear,
CSF examination or examination of other extra medullary sites.
95% children with leukemia achieve remission during
'induction, within 4 weeks.
1. Drugs used for induction in ALL are Prednisolone,
Vincristine and L-asparginase with or without Doxorubidn.
In AML for induction drugs like Cytarabine (Ara-c) and
Daunorubidn are used.
CONT……
Leukemic cells can cross the blood-brain barrier while most
chemotherapy drugs, do not cross this barrier.
Children with ALL receive CNS prophylaxis with
chemotherapy drugs instilled intrathecally, into the
cerebrospinal fluid space during lumbar puncture.
Children who present with CNS disease also need radiation
therapy.
CONSOLIDATION PHASE
The next phase of treatment is consolidation or intensification
that aims at eradicating any residual leukemic cells. This phase
of therapy begins once remission is attained.
Treatment is directed at those anatomic sites which are
protected to some extent from systemic chemotherapy like CNS
(protected by blood- brain barrier) and testes (that lie outside
the body).
CONT……
This phase involves prophylactic treatment of CNS
with cranial irradiation and or intrathecal
administration of Methotrexate.
The therapy usually consists of daily high dose
radiation treatment for about 2 weeks or twice a week
doses of Methotrexate, a total of 5-6 injections.
MAINTENANCE THERAPY
Maintenance therapy aims at preventing recurrence and
further reducing the number of leukemic cells. Maintenance
therapy begins after successful completion of induction and
consolidation phase.
Drugs frequently used in maintenance therapy are 6-
mercaptopurine and weekly doses of oral Methotrexate.
During this phase weekly or monthly complete blood count is
done, to evaluate marrow's response to drugs.
If WBC count goes below 2000/mm3 or toxic side effects occur,
then therapy is temporarily stopped or dose is reduced.
BONE MARROW TRANSPLANTATION
Bone marrow transplants have been used successfully in
treating some children with ALL and AML.
In general bone marrow transplant is not recommended for
children with ALL because of excellent results possible with
chemotherapy.
Marrow transplant is possible only when suitable donor is
available.
Prognosis after transplantation depends on type of leukemia.
Long term survival after marrow transplant is seen in 25-50%
cases.
NURSING MANAGEMENT
a. Management of problems of Leukemia
B.Management of side effects of chemotherapy and
problems of irradiation
c. Parental support and guidance
NURSING MANAGEMENT
Nursing management focuses on managing the problems of
leukemia and side effects of chemotherapy.
a. Management of problems of Leukemia
Infiltration of bone marrow with leukemic cells, leads to
myelosuppression resulting in reduced RBC, WBC and platelet
production. This ultimately leads to anemia, infections and
chances of hemorrhage. Nursing management of these problems
is as follows-
NURSING MANAGEMENT
i. Management of Anemia
Nurses should assess the leukemic children for anemia and its
severity.
Blood transfusion with packed red cells may be required to raise
hemoglobin level above 10gm /dl.
Nurse should take all precautions to prevent problems
associated with blood transfusion like transmission of blood
borne infection to the patient through transfusion of
contaminated blood, transfusion reactions etc.
Nurses should monitor the patient continuously during blood
transfusion.
NURSING MANAGEMENT
ii. Prevention from infections
Infection is the most frequent cause of death in leukemia.
Organisms most commonly infecting these children are
Varicella, Herpes zooster, MMR and polio virus, protozoa like
Pneumocystis carnii and fungi like Candida albicans. Following
measures must be taken to prevent infections-
Broad spectrum antibiotics are used prophylactically. Live
vaccines should not be given to leukemic children, as they are
already immunocompromised.
The child is in hospital, universal precautions are used along
with isolation, barrier nursing, strict handwashing and aseptic
techniques.
CONT……
Fever is a sign of infection, so if fever occurs, blood, urine, stool
and nasopharyngeal cultures are done, to identify the cause
and site of infection.
An adequate protein and calorie intake provides the child with
better host defenses against infection and increases tolerance to
chemotherapy.
NURSING MANAGEMENT
iii.Prevention and management of hemorrhage
Most of the bleeding episodes can be prevented by
administration of platelet concentrates.
Regular mouth care is essential since gingival bleeding is
frequently seen.
The child may be provided with either soft tooth brush or only
mouth wash may be used to rinse the mouth.
These children develop repeated episodes of diarrhea, so they
are prone to rectal ulceration.
CONT.…..
Provide perineal care after each loose stool and keep the area
clean and dry.
During a bleeding episode, the parents and child need
emotional support.
Children are kept away from activities that might cause injury
or bleeding.
B.MANAGEMENT OF SIDE EFFECTS OF
CHEMOTHERAPY AND PROBLEMS OF
IRRADIATION
i. Nausea and vomiting
for mild to moderate vomiting, antiemetics like promethazine
(phenargan), chlorpromazine
etc, are used.
Metaclopramide is administered for severe vomiting.
Antiemetics should be given before chemotherapy is started (30
minutes to 1 hour before
chemotherapy) and then regularly at two hours interval upto 24
hours.
NURSING MANAGEMENT
ii.Anorexia
Loss of appetite occurs because of chemotherapy and
radiation therapy so:
Give small frequent feeds to the child according to his
likes.
Give soft and easily digestable food to the child.
Serve the food in an attractive manner.
NURSING MANAGEMENT
iii. Mucosal ulceration
As a side effect of chemotherapy, the mucosa of gastrointestinal
tract becomes ulcerated. Oral ulcers develop which make eating
extremely uncomfortable so:
Give bland, moist and soft diet to the child.
Use soft tooth brush or cotton tipped applicator and mouth
wash to clean the child's mouth.
Frequent mouth wash may be provided with normal saline.
NURSING MANAGEMENT
Local anesthetics like lidocaine can be used to
anesthetize oral ulcers, before the child eats food.
Liberal fluid intake is encouraged.
Nasogastric feeds may be started in case of severe
ulceration in mouth.
• Nasogastric feeds may be started in case of severe
ulceration in mouth.
NURSING MANAGEMENT
iv. Neuropathy
Vincristine and vinblastin can cause various neurotoxic effects
leading to foot drop, weakness and numbness of extremities and
reduced bowel movements.
So Use foot board to prevent foot drop in bed ridden children.
The child suffers from constipation. Regular bowel movements
should be ensured by using stool softeners and laxatives. Also
fluid intake of the child must be increased.
NURSING MANAGEMENT
v. Hemorrhagic cystitis
The drug Cyclophosphamide leads to hemorrhagic cystitis. It
can be prevented by:
Liberal fluid intake.
Motivate the child to void immediately on feeling the urge to
urinate.
Administer chemotherapy drugs in the morning, to allow for
sufficient intake of oral fluids and frequent voiding or urination.
NURSING MANAGEMENT
vi. Alopecia
Hair loss occurs because of chemotherapy and cranial
irradiation, so:—
Inform the parents and child about this side effect earlier.
Encourage the parents to purchase a wig for child, before hair
fall occurs.
Child's hair should be cut short and he should be made to wear
surgical cap to collect the fallen hair.
Parents and child should be reassured that hair will grow again
after the treatment stops.
NURSING MANAGEMENT
vii. Mood changes
Shortly after starting of steroid therapy, children experience
mood changes which range from
feeling of wellbeing and euphoria to depression and irritability.
Parents should be made aware of these behavior changes.
NURSING MANAGEMENT
c. Parental support and guidance
Nurses should continually guide, support and help parents to
adjust to this disease condition.
Parents should be encouraged to express their feelings, fear,
grief and concerns.
Provide emotional support to the parents continuously.
