Chapter 4 Leu-101856

Hematology and Oncology Nursing Care / H.
AKOUM
CHAPTER III
1
Management of Hematologic
Disorders: Leukemias
ACUTE LYMPHOCYTIC AND ACUTE
MYELOGENOUS LEUKEMIA
 Leukemias are malignant disorders of the blood and
bone marrow that result in an accumulation of
dysfunctional, immature cells that are caused by loss of
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Hematology and Oncology Nursing Care / H.AK
regulation of cell division.
 They are classified as acute or chronic based on the
development rate of symptoms, and further classified by the
predominant cell type.
 Acute leukemias affect immature cells and are characterized
by rapid progression of symptoms. When lymphocytes are
the predominant malignant cell, the disorder is acute
lymphocytic leukemia (ALL); when monocytes or
granulocytes are predominant, it is acute myelogenous
2
leukemia (AML), sometimes called acute nonlymphocytic
leukemia.
PATHOPHYSIOLOGY AND ETIOLOGY
 The development of leukemia has been associated with:
 Exposure to ionizing radiation.
 Exposure to certain chemicals and toxins (eg, benzene, alkylating agents).
 Human T-cell leukemia lymphoma virus (HTLV-1 and HTLV-2) in certain
areas of the world, including the Caribbean and southern Japan.
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 Familial susceptibility.
 Genetic disorders (eg, Down syndrome, Fanconi's anemia).
 Approximately half of new leukemias are acute. Approximately
85% of acute leukemias in adults are AML. ALL is most common
in children, with peak incidence between ages 2 and 9.
 Childhood ALL is usually cured with chemotherapy alone (> 75%),
whereas only 30% to 40% of adults with ALL are cured.
 AML is a disease of older people, with a median age at diagnosis of
67. Even in the young-old (patients who are younger than age 60),
AML is difficult to treat, with a median survival of 5 to 6 months, 3
despite intensive therapy.
CLINICAL MANIFESTATIONS
 Common symptoms include pallor, fatigue, weakness,

fever, weight loss, abnormal bleeding and bruising,
lymphadenopathy (in ALL), and recurrent infections (in
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ALL).
 Other presenting symptoms may include bone and joint
pain, headache, splenomegaly, hepatomegaly, neurologic
dysfunction.
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DIAGNOSTIC EVALUATION
 CBC and blood smear peripheral WBC count varies

widely from 1,000 to 100,000/mm3 and may include
significant numbers of abnormal immature (blast) cells;
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anemia may be profound; platelet count may be
abnormal and coagulopathies may exist.
 Bone marrow aspiration and biopsy cells also studied for
chromosomal abnormalities (cytogenetics) and
immunologic markers to classify type of leukemia
further.
 Lymph node biopsy to detect spread.
 Lumbar puncture and examination of cerebrospinal fluid
5
for leukemic cells (especially in ALL).
MANAGEMENT
 To eradicate leukemic cells and allow restoration of
normal hematopoiesis.
 High-dose chemotherapy given as an induction course to
obtain a remission (disappearance of abnormal cells in bone
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marrow and blood) and then in cycles as consolidation or
maintenance therapy to prevent recurrence of disease
 Leukapheresis (or exchange transfusion in infants) may be
used when abnormally high numbers of white cells are
present to reduce the risk of leukostasis and tumor burden
before chemotherapy.
 Radiation, particularly of central nervous system (CNS) in
ALL.
 Autologous or allogeneic bone marrow or stem cell
transplantation.
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 Supportive care and symptom management.
COMPLICATIONS
 Leukostasis: in setting of high numbers (greater than
50,000/mm3) of circulating leukemic cells (blasts), blood
vessel walls are infiltrated and weakened, with high risk of
rupture and bleeding, including intracranial
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hemorrhage.
 Disseminated intravascular coagulation (DIC).
 Tumor lysis syndrome: rapid destruction of large numbers

of malignant cells leads to alterations in electrolytes
(hyperuricemia, hyperkalemia, hyperphosphatemia,
and hypocalcemia).
 May lead to renal failure and other complications.
 Infection, bleeding, organ damage.

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NURSING ASSESSMENT
 Take nursing history, focusing on weight loss, fever,
frequency of infections, progressively increasing
fatigability, shortness of breath, palpitations, visual
changes (retinal bleeding).
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 Ask about difficulty in swallowing, coughing, rectal
pain.
 Examine patient for enlarged lymph nodes,
hepatosplenomegaly, evidence of bleeding, abnormal
breath sounds, skin lesions.
 Look for evidence of infection: mouth, tongue, and
throat for reddened areas or white patches. Examine skin
for breakdown, which is a potential source of infection.
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NURSING DIAGNOSES
1. Risk for infection and bleeding
2. Risk for impaired skin integrity related to toxic effects of
chemotherapy, alteration in nutrition, and impaired mobility
3. Impaired gas exchange
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4. Impaired mucous membranes due to changes in epithelial lining
of the gastrointestinal tract from chemotherapy or prolonged use
of antimicrobial medications
5. Imbalanced nutrition, less than body requirements, related to
hypermetabolic state, anorexia, mucositis, pain, and nausea
6. Acute pain and discomfort related to mucositis, WBC infiltration
of systemic tissues, fever, and infection
7. Hyperthermia related to tumor lysis and infection
8. Fatigue and activity intolerance related to anemia and infection
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9. Impaired physical mobility due to anemia and protective isolation
NURSING DIAGNOSES
10. Risk for excess fluid volume related to renal dysfunction,
hypoproteinemia, need for multiple intravenous medications and blood
products
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11. Diarrhea due to altered gastrointestinal flora, mucosal denudation
12. Risk for deficient fluid volume related to potential for diarrhea, bleeding,
infection, and increased metabolic rate
13. Self-care deficit due to fatigue, malaise, and protective isolation
14. Anxiety due to knowledge deficit and uncertain future
15. Disturbed body image related to change in appearance, function, and
roles
16. Grieving related to anticipatory loss and altered role functioning
17. Potential for spiritual distress
18. Deficient knowledge about disease process, treatment, complication 10
management, and self-care measures
COLLABORATIVE PROBLEMS/
POTENTIAL COMPLICATIONS
Based on the assessment data, potential complications that

may develop include:
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 Infection
 Bleeding
 Renal dysfunction
 Tumor lysis syndrome
 Nutritional depletion
 Mucositis
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NURSING INTERVENTIONS
1. Preventing Infection
 Especially monitor for pneumonia, pharyngitis, esophagitis, perianal cellulitis,
urinary tract infection, and cellulitis, which are common in leukemia and
which carry significant morbidity and mortality.
 Monitor for fever, flushed appearance, chills, tachycardia; appearance of
white patches in mouth; redness, swelling, heat or pain of eyes, ears, throat,
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skin, joints, abdomen, rectal and perineal areas; cough, changes in sputum;
skin rash.
 Check results of granulocyte counts. Concentrations less than 500/mm 3 put
the patient at serious risk for infection.
 Avoid invasive procedures and trauma to skin or mucous membrane to
prevent entry of microorganisms.
 Use the following rectal precautions to prevent infection:
 Avoid diarrhea and constipation, which can irritate the rectal mucosa.
 Avoid use of rectal thermometers.
 Keep perianal area clean.
 Care for patient in private room with strict hand-washing practice. Patients
with prolonged neutropenia may benefit from HEPA filtration. 12
 Encourage and assist patient with personal hygiene, bathing, and oral care.
 Obtain cultures and administer antimicrobials promptly as directed.
2. Preventing and Managing Bleeding
Prevent Complications
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 Avoid aspirin and aspirin-containing medications or other medications
known to inhibit platelet function, if possible.
 Do not give intramuscular injections.
 Do not insert indwelling catheters.
 Take no rectal temperatures; do not give suppositories, enemas.
 Use stool softeners, oral laxatives to prevent constipation.
 Use smallest possible needles when performing venipuncture.
 Apply pressure to venipuncture sites for 5 min or until bleeding has

stopped.
 Permit no flossing of teeth and no commercial mouthwashes. 13
 Use only soft-bristled toothbrush for mouth care.

 Use only toothettes for mouth care if platelet count is
<10,000/mm3, or if gums bleed.
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 Lubricate lips with water-soluble lubricant every 2 hr
while awake.
 Avoid suctioning if at all possible; if unavoidable, use
only gentle suctioning.
 Discourage vigorous coughing or blowing of the nose.
 Use only electric razor for shaving.
 Pad side rails as needed.
 Prevent falls by ambulating with patient as necessary

14
Control Bleeding
 Apply direct pressure.
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 For epistaxis, position patient in high Fowler’s position;
apply ice pack to back of neck and direct pressure to
nose.
 Notify physician for prolonged bleeding (eg, unable to
stop within 10 min).
 Administer platelets, fresh frozen plasma, packed red
blood cells,as prescribed.
15
3. MANAGING MUCOSITIS
4. IMPROVING NUTRITIONAL INTAKE
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5. EASING PAIN AND DISCOMFORT
6. DECREASING FATIGUE AND DECONDITIONING
7. MAINTAINING FLUID AND ELECTROLYTE BALANCE
8. IMPROVING SELF-CARE
9. MANAGING ANXIETY AND GRIEF
10. ENCOURAGING SPIRITUAL WELL-BEING
11. MONITORING AND MANAGING POTENTIAL
COMPLICATIONS
16
12. Patient Education and Health Maintenance
 Teach infection precautions .
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 Teach signs and symptoms of infection and advise whom
to notify.
 Encourage adequate nutrition to prevent emaciation from
chemotherapy.
 Teach avoidance of constipation with increased fluid and
fiber, and good perianal care.
 Teach bleeding precautions.
 Encourage regular dental visits to detect and treat dental

infections and disease. 17
EVALUATION: EXPECTED OUTCOMES
1. Shows no evidence of infection
2. Experiences no bleeding
3. Has intact oral mucous membranes
a. Participates in oral hygiene regimen
b. Reports no discomfort in mouth
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4. Attains optimal level of nutrition
a. Maintains weight with increased food and fluid intake
b. Maintains adequate protein stores (albumin)
5. Reports satisfaction with pain and discomfort levels
6. Has less fatigue and increased activity
7. Maintains fluid and electrolyte balance
8. Participates in self-care
9. Copes with anxiety and grief
a. Discusses concerns and fears
b. Uses stress management strategies appropriately
18
c. Participates in decisions regarding end-of-life care
10. Absence of complications
CHRONIC MYELOGENOUS LEUKEMIA
 Chronic myelogenous leukemia (CML) (ie, involving

more mature cells than acute leukemia) is characterized
by proliferation of myeloid cell lines, including
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granulocytes, monocytes, platelets, and occasionally
RBCs.
19
 Specific etiology unknown, associated with exposure to
ionizing radiation and family history of leukemia.
Results from malignant transformation of pluripotent
hematopoietic stem cell.
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 First cancer associated with chromosomal abnormality
(the Philadelphia [Ph] chromosome), present in more
than 90% of patients.
 Accounts for 25% of adult leukemias and less than 5%
of childhood leukemias. Generally presents between ages
25 and 60 with peak incidence in the mid-40s.
 With progression of illness, enters terminal phase,
resembling an acute leukemia that consists of accelerated
phase or blast crisis. 20
 Insidious onset, may be discovered during routine

physical examination.
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 Common symptoms include fatigue, pallor, activity
intolerance, fever, weight loss, night sweats, abdominal
fullness (splenomegaly).
21
 CBC and blood smear: large numbers of granulocytes

(usually more than 100,000/mm3), platelets may be
decreased.
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 Bone marrow aspiration and biopsy: hypercellular,
usually demonstrates Philadelphia (Ph1) chromosome.
22
COMPLICATIONS
 Leukostasis.
 Infection, bleeding, organ damage.
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23
NURSING ASSESSMENT
 Obtain health history, focusing on fatigue, weight loss,

night sweats, activity intolerance.
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 Assess for signs of bleeding and infection.
 Evaluate for splenomegaly, hepatomegaly.
 Assess for weight gain and edema in patients taking

imatinib.
24
NURSING DIAGNOSIS
 Fear related to disease progression and death
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25
Allaying Fear
 Encourage appropriate verbalization of feelings and
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concerns.
 Provide comprehensive patient teaching about disease,
using methods and content appropriate to patient's needs.
 Assist patient in identifying resources and support (eg,
family and friends, spiritual support, community or
national organizations, support groups).
 Facilitate use of effective coping mechanisms.
26
Patient Education and Health Maintenance
 Teach patient to take medications as prescribed and
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monitor for adverse effects.
 Teach patient method of subcutaneous injection for self-
administration of alpha interferon, and teach strategies
for managing such adverse effects as fatigue and fevers.
27
 Demonstrates effective coping skills
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28
CHRONIC LYMPHOCYTIC LEUKEMIA
 Chronic lymphocytic leukemia (CLL) (ie, involving

more mature cells than acute leukemia) is characterized
by proliferation of morphologically normal but
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functionally inert lymphocytes.
29
 Specific etiology unknown. Tends to cluster in families,

much more common in Western hemisphere. Male
hormones may play role.
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 Most common adult leukemia in United States and
Europe. Disease of later years (90% over age 50); twice
as common in men than in women.
 Lymphocytes are immunoincompetent and respond
poorly to antigenic stimulation.
 In late stages, organ damage may occur from direct
lymphocytic infiltration of tissue.
 May be indolent for years, with gradual transformation
30
to more malignant disease.
 Insidious onset, may be discovered during routine

physical examination.
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 Early symptoms may include history of frequent skin or
respiratory infections, symmetrical lymphadenopathy,
mild splenomegaly.
 Symptoms of more advanced disease include pallor,
fatigue, activity intolerance, easy bruising, skin lesions,
bone tenderness, abdominal discomfort.
31
 CBC and blood smear: large numbers of lymphocytes

(10,000 to 150,000/mm3); may also be anemia,
thrombocytopenia, hypogammaglobulinemia.
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 Bone marrow aspirate and biopsy: lymphocytic
infiltration of bone marrow.
 Lymph node biopsy to detect spread.
32
MANAGEMENT
Symptom Control and Treatments
 Patient with newly diagnosed CLL is generally observed and
followed closely until symptoms develop.
 Lymphocyte proliferation can be suppressed with chlorambucil
(Leukeran), cyclophosphamide (Cytoxan), and prednisone (Orasone).
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 B cell CLL may be treated with fludarabine (Fludara).
 Monoclonal antibodies such as alemtuzumab (Campath) and

rituximab (Rituxan) may be used.
 Hairy cell leukemia, a distinctive type of B cell leukemia with
hairlike projections of cytoplasm from lymphocytes, may be
successfully treated with cladribine (Leustatin), pentostatin (Nipent),
or alpha interferon.
 Splenic irradiation or splenectomy for painful splenomegaly or
platelet sequestration, hemolytic anemia.
 Irradiation of painful enlarged lymph nodes.
 Bone marrow transplant and combinations of alpha interferon and

33
interleukin-2 are also used to treat CLL.
MANAGEMENT
Supportive Care
 Transfusion therapy to replace platelets and RBCs.
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 Antibiotics, antivirals, and antifungals as needed to
control infections.
 I.V. immunoglobulins or gamma globulin to treat
hypogammaglobulinemia.
34
COMPLICATIONS
 Thrombophlebitis from venous or lymphatic obstruction

caused by enlarged lymph nodes.
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 Infection, bleeding.
 Median survival depends on severity of disease; varies

from 2 to 7 years.
35
NURSING ASSESSMENT
 Obtain health history, focusing on history of infections,

fatigue, bruising and bleeding, swollen lymph nodes.
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 Assess for signs of anemia, bleeding, or infection.
 Evaluate for splenomegaly, hepatomegaly,

lymphadenopathy.
36
NURSING DIAGNOSES
 Acute pain related to tumor growth, infection, or adverse

effects of chemotherapy
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 Activity Intolerance related to anemia and adverse
effects of chemotherapy
37
1. Reducing Pain
 Assess patient frequently for pain and administer or
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teach patient to administer analgesics on regular
schedule, as prescribed; monitor for adverse effects.
 Teach patient the use of nonpharmacologic methods,
such as the use of music, relaxation breathing,
progressive muscle relaxation, distraction, and imagery
to help to manage pain.
38
2. Improving Activity Tolerance
 Encourage frequent rest periods alternating with
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ambulation and light activity as tolerated.
 Assist patient with hygiene and physical care as
necessary.
 Encourage balanced diet or nutritional supplements as
tolerated.
 Teach patient to use energy conservation techniques
while performing activities of daily living, such as sitting
while bathing, minimizing trips up and down stairs,
using shoulder bag or push cart to carry articles.
39
3.Patient Education and Health Maintenance
 Teach patient to minimize risk of infection .
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 Teach patient use of medications as ordered, and possible
adverse effects and their management; also teach patient
to avoid aspirin and NSAIDs, which may interfere with
platelet function
40
 States free from pain

 Performs activities without complaints of fatigue
OUM
41

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Chapter 4 Leu-101856

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Hematology and Oncology Nursing Care / H.

 Common symptoms include pallor, fatigue, weakness,

 CBC and blood smear peripheral WBC count varies

 Tumor lysis syndrome: rapid destruction of large numbers

 Infection, bleeding, organ damage.

Based on the assessment data, potential complications that

 Tumor lysis syndrome

 Do not insert indwelling catheters.

 Take no rectal temperatures; do not give suppositories, enemas.

 Use stool softeners, oral laxatives to prevent constipation.

 Use smallest possible needles when performing venipuncture.

 Apply pressure to venipuncture sites for 5 min or until bleeding has

 Use only soft-bristled toothbrush for mouth care.

 Use only electric razor for shaving.

 Pad side rails as needed.

 Prevent falls by ambulating with patient as necessary

 Encourage regular dental visits to detect and treat dental

 Chronic myelogenous leukemia (CML) (ie, involving

 Insidious onset, may be discovered during routine

 CBC and blood smear: large numbers of granulocytes

 Obtain health history, focusing on fatigue, weight loss,

 Evaluate for splenomegaly, hepatomegaly.

 Assess for weight gain and edema in patients taking

 Fear related to disease progression and death

 Demonstrates effective coping skills

 Chronic lymphocytic leukemia (CLL) (ie, involving

 Specific etiology unknown. Tends to cluster in families,

 Insidious onset, may be discovered during routine

 CBC and blood smear: large numbers of lymphocytes

 Monoclonal antibodies such as alemtuzumab (Campath) and

 Bone marrow transplant and combinations of alpha interferon and

 Thrombophlebitis from venous or lymphatic obstruction

 Median survival depends on severity of disease; varies

 Obtain health history, focusing on history of infections,

 Evaluate for splenomegaly, hepatomegaly,

 Acute pain related to tumor growth, infection, or adverse

 States free from pain

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