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I.

LEUKEMIA

Leukemias are cancers of the blood-forming tissues. White blood cells may be produced in excessive amounts and are unable to work properly which weakens the immune system. Blood cells are formed in the bone marrow, the soft, spongy center of bones. New (immature) blood cells are called blasts. Some blasts stay in the marrow to mature. Some travel to other parts of the body to mature. Normally, blood cells are produced in an orderly, controlled way, as the body needs them. This process helps keep us healthy. When leukemia develops, the body produces large numbers of abnormal blood cells. In most types of leukemia, the abnormal cells are white blood cells. The leukemia cells usually look different from normal blood cells, and they do not function properly. In both men and women, leukemia incidence is highest among whites and lowest among Chinese, Japanese, and Koreans. The incidence in men is about 50% higher than in women for all racial/ethnic groups except Vietnamese, among whom the male rates are only slightly higher. Ethnic differences in the incidence rates are small in the youngest adult age group (30-54 years), but become more evident in each of the older age groups. It is found that childhood leukemia rates are highest among Filipinos, followed by white Hispanics, non-Hispanic whites and blacks. Anatomy and physiology

Blood Blood is one of the connective tissues. As a connective tissue, it consists of cells and cell fragments (formed elements) suspended in an intercellular matrix (plasma). Blood is the only liquid tissue in the body that measures about 5 liters in the adult human and accounts for 8 percent of the body weight. The body consists of metabolically active cells that need a continuous supply of nutrients and oxygen. Metabolic waste products need to be removed from the cells to maintain a stable cellular environment. Blood is the primary transport medium that is responsible for meeting these cellular demands.

Blood cells are formed in the bone marrow, the soft, spongy center of bones. New (immature) blood cells are called blasts. Some blasts stay in the marrow to mature. Some travel to other parts of the body to mature. The activities of the blood may be categorized as transportation, regulation, and protection. These functional categories overlap and interact as the blood carries out its role in providing suitable conditions for celluar functions. The transport functions include:
  

carrying oxygen and nutrients to the cells. transporting carbon dioxide and nitrogenous wastes from the tissues to the lungs and kidneys where these wastes can be removed from the body. Carrying hormones from the endocrine glands to the target tissues.

The regulation functions include:


  

Helping regulate body temperature by removing heat from active areas, such as skeletal muscles, and transporting it to other regions or to the skin where it can be dissipated. Playing a significant role in fluid and electrolyte balance because the salts and plasma proteins contribute to the osmotic pressure. Functioning in pH regulation through the action of buffers in the blood.

The protection functions include:


  

Preventing fluid loss through hemorrhage when blood vessels are damaged due to its clotting mechanisms. Helping (phagocytic white-blood cells) to protect the body against microorganisms that cause disease by engulfing and destroying the agent. Protecting (antibodies in the plasma) protect against disease by their reactions with offending agents.

Composition of blood

When a sample of blood is spun in a centrifuge, the cells and cell fragments are separated from the liquid intercellular matrix. Because the formed elements are heavier than the liquid matrix, they are packed in the bottom of the tube by the centrifugal force. The light yellow colored liquid on the top is the plasma, which accounts for about 55 percent of the blood volume and red blood cells is called the hematocrit,or packed cell volume (PCV). The white blood cells and platelets form a thin white layer, called the buffy coat, between plasma and red blood cells. Plasma The watery fluid portion of blood (90 percent water) in which the corpuscular elements are suspended. It transports nutrients as well as wastes throughout the body. Various compounds, including proteins, electrolytes, carbohydrates, minerals, and fats, are dissolved in it. Formed Elements The formed elements are cells and cell fragments suspended in the plasma. The three classes of formed elements are the erythrocytes (red blood cells), leukocytes (white blood cells), and the thrombocytes (platelets). y Erythrocytes (red blood cells) Erythrocytes, or red blood cells, are the most numerous of the formed elements. Erythrocytes are tiny biconcave disks, thin in the middle and thicker around the periphery. The shape provides a combination of flexibility for moving through tiny capillaries with a maximum surface area for the diffusion of gases. The primary function of erythrocytes is to transport oxygen and, to a lesser extent, carbon dioxide. y Leukocytes (white blood cells) Leukocytes or white blood cells are generally larger than erythrocytes, but they are fewer in number. Even though they are considered to be blood cells, leukocytes do most of their work in the

tissues. They use the blood as a transport medium. Some are phagocytic, others produce antibodies, some secrete histamine and, heparin, and others neutralize histamine. Leukocytes are able to move through the capillary walls into the tissue spaces, a process called diapedesis. In the tissue spaces they provide a defence against organisms that cause disease and either promote or inhibit inflammatory responses. There are two main groups of leukocytes in the blood. The cells that develop granules in the cytoplasm are called granulocytes and those that do not have granules are called agranulocytes. Neutrophils, eosinophils, and basophils are granulocytes. Monocytes and lymphocytes are agranulocytes. Neutrophils, the most numerous leukocytes, are phagocytic and have light-colored granules. Eosinophils have granules and help counteract the effects of histamine. Basophils secrete histomine and heparin and have blue granules. In the tissues, they are called mastcells. Lymphocytes are agranulocytes that have a special role in immune processes. Some attack bacteria directly; others produce antibodies. y Thrombocytes (platelets) Thrombocytes, or platelets, are not complete cells, but are small fragments of very large cells called megakaryocytes. Megakaryocytes develop from hemocytoblasts in the red bone marrow. Thrombocytes become sticky and clump together to form platelet plugs that close breaks and tears in blood vessels. They also initiate the formation of blood clots. Blood Cell Lineage:

The production of formed elements, or blood cells, is called hemopoiesis. Before birth, hemopoiesis occurs primarily in the liver and spleen, but some cells develop in the thymus, lymph nodes, and redbone marrow. After birth, most production is limited to red bone marrow in specific regions, but some white blood cells are produced in lymphoid tissue. All types of formed elements develop from a single cell type stem cell (pleuripotential cells or hemocytoblasts). Seven different cell lines, each controlled by a specific growth factor, develop from the

hemocytoblast. When a stem cell divides, one of the daughters remains a stem cell and the other becomes a precursor cell, either alymphoid cell or a myeloid cell. These cells continue to mature into various blood cells. A leukemia can develop at any point in cell differentiation. The illustration below shows the development of the formed elements of the blood. Blood-related cancers, or leukemias, have been shown to arise from a rare subset of cells that escape normal regulation and drive the formation and growth of the tumor. The finding that these socalled cancer stem cells, or leukemic stem cells (LSC), can be purified away from the other cells in the tumor allows their precise analysis to identify candidate molecules and regulatory pathways that play a role in progression, maintenance, and spreading of leukemias. The analyses of the other, numerically dominant, cells in the tumor, while also interesting, do not directly interrogate these key properties of malignancies. Mouse models of human myeloproliferative disorder and acute myelogenous leukemia have highlighted the remarkable conservation of disease mechanisms between both species. They can now be used to identify the LSC for each type of human leukemia and understand how they escape normal regulation and become malignant. Given the clinical importance of LSC identification, the insights gained through these approaches will quickly translate into clinical applications and lead to improved treatments for human leukemias. Leukemia Cells In a person with leukemia, the bone marrow makes abnormal white blood cells. The abnormal cells are leukemia cells. Unlike normal blood cells, leukemia cells don't die when they should. They may crowd out normal white blood cells, red blood cells, and platelets. This makes it hard for normal blood cells to do their work. Types of Leukemia The types of leukemia can be grouped based on how quickly the disease develops and gets worse. Leukemia is either chronic (which usually gets worse slowly) or acute (which usually gets worse quickly):
 Chronic leukemia: Early in the disease, the leukemia cells can still do some of the work of normal

white blood cells. People may not have any symptoms at first. Doctors often find chronic leukemia during a routine checkup - before there are any symptoms. Slowly, chronic leukemia gets worse. As the number of leukemia cells in the blood increases, people get symptoms, such as swollen lymph nodes or infections. When symptoms do appear, they are usually mild at first and get worse gradually.
 Acute leukemia: The leukemia cells can't do any of the work of normal white blood cells. The

number of leukemia cells increases rapidly. Acute leukemia usually worsens quickly.

The types of leukemia also can be grouped based on the type of white blood cell that is affected. Leukemia can start in lymphoid cells or myeloid cells. Leukemia that affects lymphoid cells is called lymphoid, lymphocytic, or lymphoblastic leukemia. Leukemia that affects myeloid cells is called myeloid, myelogenous, or myeloblastic leukemia. There are four common types of leukemia:
y

Chronic lymphocytic leukemia (CLL): CLL affects lymphoid cells and usually grows slowly. It accounts for more than 15,000 new cases of leukemia each year. Most often, people diagnosed with the disease are over age 55. It almost never affects children.
 Chronic myeloid leukemia (CML): CML affects myeloid cells and usually grows slowly at first.

It accounts for nearly 5,000 new cases of leukemia each year. It mainly affects adults.
 Acute lymphocytic (lymphoblastic) leukemia (ALL): ALL affects lymphoid cells and grows

quickly. It accounts for more than 5,000 new cases of leukemia each year. ALL is the most common type of leukemia in young children. It also affects adults.
 Acute myeloid leukemia (AML): AML affects myeloid cells and grows quickly. It accounts for

more than 13,000 new cases of leukemia each year. It occurs in both adults and children.  Hairy cell leukemia is a rare type of chronic leukemia. II. Risk Factors:  Ionizing radiation exposures such as radiation therapy for cancer treatment or environmental irradiation increase the risk for leukemia development, particularly acute myelogenous leukemia (AML).  Certain chemicals and drugs have been linked to the development of leukemia because of their ability to damage DNA. Previous treatment for cancer that included melphaplan, cyclosphamide, doxorubicin, and etoposide poses risks for leukemia development about 5 to 8 years after treatment.  Bone marrow hypoplasia can increase leukemia risk by reducing or changing bone marrow cell production. Disorders that have marrow hypoplasia and may lead to leukemia development include Fanconi s anemia, paroxysmal nocturnal hemoglobinuria, and myelodysplastic syndromes.  Genetic factors influence leukemia development. There is an increased incidence of the disease among clients with hereditary conditions such as Down syndrome, blooms syndrome, Klinefelter syndrome, and Fanconi s anemia. Identical siblings of client with leukemia have a higher rate of leukemia than do general population.  Immunologic factors, especially immune deficiencies, may promote the development of leukemia. Leukemia among immunodeficient people may be a result of immune surveilance failure, or the same mechanisms that cause the immune deficiency may also trigger cancer in the white blood cells population.

 Interaction of many host and environmental factors may result in leukemia. Because each person tolerates the interaction of these factors differently, it is difficult to determine the origin of any specific leukemia. III. Clinical Manifestions:  Integumentary Manifestations: y Ecchymoses y Petechiae y Open infected lesions y Pallor of the conjunctiva, nail beds, palmar creases and around the mouth  Gastrointestinal Manifestations: y y y y Bleeding gums Anorexia Weight loss Enlarged liver and spleen

 Renal Manifestations: y Hematuria

 Cardiovascular Manifestations: y y y Tachycardia at basal activity levels Orthostatic hypotension Palpitations

 Respiratory Manifestations: y Dyspnea on exertion

 Neurologic Manifestations: y y y Fatigue Headache Fever

 Musculoskeletal Manifestations: y y Bone pain Joint swelling and pain

IV.

Diagnostic Evaluation:  Complete Blood Count (CBC) and Blood Smear y Peripheral white blood cells (WBC) count varies widely from 1,000 to 10,000/mm3 and may include significant numbers of abnormal immature (blast) cells, anemia may be profound, platelet count may be abnormal and coagulopathies may exist. y y Differential reveals one type of leukocytes is overwhelmingly predominant. Hemoglobin level is low.

 Bone Marrow Aspiration and Biopsy y y Cells also studied for chromosomal abnormalities (cytogenetics) and immunologic markers to classify type of leukemia further. Overall increase in the number of marrow cells and increase in the proportion of immature cells.  Lymph Node Biopsy/Lymphangiography y y Used to detect the spread. Used to locate malignant lesions and classify the disease accurately.

 Lumbar Puncture and Examination of Cerebrospinal Fluid for leukemic cells (especially ALL)  Radiography of the chest and skeleton, MRI and CT Scan y V. Detect lesions and sites of infection.

Medical Management: ACUTE LEUKEMIA

The goal of acute leukemia is to complete remission with restoration of normal bone marrow function; this means a level of blast cells in the marrow less than 5%. Destruction of Neoplastic Cells 1. Chemotherapy- given to destroy the malignant cell of the bone marrow. 2. Radiation Therapy- may administered as an adjunct to chemotherapy when leukemia cells infiltrate the CNS, skin, rectum, and testes or when large mediastinal mass is noted at diagnosis. 3. Targeted Therapy- when AMLL relapses, treatment options are limited because of associated toxicities and health status of the client. 4. Treat or prevent Tumor Lysis Syndrome- potential fatal complication resulting from treatment of acute leukemia.

- Tumor Lysis Syndrome is a group of metabolic complication associated with the rapid destruction of a large number of WBC. CHRONIC MYELOGENOUS LEUKEMIA The goal of chronic phase of CML is to control leukocytosis and thrombocytosis. Targeted Therapy  Imatinib mesylate (Gleevac) - inhibits proliferation and induces apoptosis by inhibiting tyrosine kinase activity in cells positive for bcr-abl.  Dasatinib (Sprycel) - is a newer drug in the class of tyrosine kinase inhibitors that often work to treat CML in clients when imatinib does not.  Nilotinib (Tasigna) - this oral agent is indicated for use in the treat of chronic phase and accelerated phase Philadelphia chromosome positive chronic myelogenous leukemia (CML) in adult patients resistant or intolerant to prior therapy included imatinib. CHRONIC LYMPHOCYTIC LEUKEMIA The goal of therapy in CLL is palliation or control of undesired manifestation. Local radiation to the Spleen may be given as palliative treatment to reduce complication. Chemotherapy  Chlorambucil (Leukeran) or Cyclophosphamide (Cyloxan) - given orally to reduce the manifestation of CLL. Chemotherapy is given 2 weeks of every month.  Prednisone - given orally daily when anemia (Stage III) and thrombocytopenia (Stage IV) develop as an adjunct to the alkylating agents. Prednisone is marked lymphocytolytic effect and may stimulate the production of RBC and platelets.  Fludarabine (Fludara) classified as nucleoside analog, is another chemotherapeutic agent that is used in treating CLL. Targeted Therapy Alemtuzumab (Campath) is a monoclonal antibody approved by the FDA for the treatment of CLL in clients who have been treated with alkylating agents and for whom Fludarabine therapy has not been successful.

VI.

Surgical Management BONE MARROW TRANSPLANTATION

To achieve cure with acute leukemia, bone marrow transplantation is the most current recommended treatment. Allogeneic BMT presents a treatment option for clients younger than 60 -70 years of age, depending on the clients performance status, who have a suitable HLA-matched donor. VII. Pharmacologic Interventions ACUTE LEUKEMIA Different types of leukemia are best treated with different kinds of medicine.  Acute lymphoblastic leukemia (ALL) drugs include prednisone, vincristine, daunorubicin, Lasparaginase or pegaspargase, methotrexate, and cyclophosphamide. Imatinib (Gleevec) is sometimes used to treat ALL. Dasatinib (Sprycel) is a newer drug for treating some ALL that has not improved with other drugs.  Acute myelogenous leukemia (AML) drugs include daunorubicin, idarubicin, cytosine arabinoside, and mitoxantrone. Gemtuzumab (Mylotarg) may be given to people whose AML has relapsed. It helps your body destroy cancer cells.  Acute promyelocytic leukemia (APL) drugs include all-trans-retinoic acid (ATRA) and chemotherapy with arsenic trioxide, idarubicin, or daunorubicin. ATRA helps control the risk of life-threatening bleeding from disseminated intravascular coagulation (DIC). Later treatment can include ATRA with or without methotrexate and 6-mercaptopurine. Or if a first round of ATRA and chemotherapy does not work, arsenic trioxide may be used.  To treat leukemia in the brain or prevent it from spreading to the brain and central nervous system, methotrexate and cytarabine/cytosine arabinoside are injected into the spinal canal. This is called intrathecal chemotherapy. Supportive treatments during cancer treatment include:  Antibiotics and immunoglobulins help to prevent or fight infections. This is important when you do not have enough normal white blood cells to fight infections on your own.  Transfusions of red blood cells and platelets.  Epoetin and hematopoietic stimulants help your body make new blood cells.  Allopurinol to prevent kidney problems and gout.  Saline or steroid eyedrops for relief during treatment with cytarabine/cytosine arabinoside. CHRONIC LEUKEMIA  Chemotherapy for chronic leukemia can involve a single drug or a combination of drugs. For example, you may be given a combination of cyclophosphamide, vincristine, and prednisone.

    

Other drug choices include fludarabine, chlorambucil, hydroxyurea (hydroxycarbamide),cytarabine, busulfan, rituximab, and alemtuzumab. Allopurinol may be given to prevent kidney problems and gout. Dasatinib (Sprycel) blocks the growth of cancer cells. It can be used for CML that has not been helped by imatinib or other drugs. Imatinib (Gleevec) blocks the growth of cancer cells. It is often given to people who havechronic myelogenous leukemia (CML). Immune globulin (IG) helps prevent infections. It is sometimes used for people with chronic lymphocytic leukemia (CLL), because CLL weakens the immune system. Interferon alfa helps your immune system fight disease and may keep cancer cells from growing. It is often given to people who have CML.

Medication for nausea and vomiting Nausea and vomiting are common side effects of chemotherapy. These side effects usually are temporary and go away when treatment is stopped. Your doctor will prescribe drugs to help relieve nausea. These may include:
    

Aprepitant (Emend), which is used in combination with ondansetron and dexamethasone as part of a 3-day program. Dimenhydrinate, such as Dramamine. Metoclopramide, such as Reglan and Octamide. Phenothiazines, such as Compazine and Phenergan. Serotonin antagonists, such as ondansetron (Zofran), granisetron (Kytril), or dolasetron (Anzemet). These drugs work best when they are combined with corticosteroids such as dexamethasone (Hexadrol).

VIII.

Nursing Care Plan Cues Diagnosis Decreased Cardiac Output related to thrombocytopenia secondary to either leukemia or treatment. Analysis Thrombocytopenia is a disorder in which there are too few platelets in the blood. Platelets are small, disk-shaped cellular fragments in the bloodstream that help the blood to clot. Thus, thrombocytopenia is often characterized by excessive bleeding, including nosebleeds and easy bruising. Thrombocytopenia can be diagnosed by a routine blood test. Goals and objectives Goals: After 8 hours of nursing intervention the client will able to decrease the bleeding. Objectives: 1. After 1 hour the client will know the different drugs. Nursing Intervention Rationale Evaluation After 8 hours of nursing intervention the client was able to decrease the bleeding.

SI had bruise and nosebleed before I send here in the hospital. as verbalized by the client. O -Many bruise in the arms and neck. - 2 times a day nose bleeds. - noted bleed gums. MWBC= 2,000/mm3 Hgb= 6 g/dl BP- 90/70 T- 38 C RR- 8 bpm PR- 42 bpm

Dependent: 1. Give anticoagulant drugs as prescribed.

>to prevent bleeding. (Ref: page 2122 of Medical Surgical Nursing Vol. 2)

2. After 4 hours the client will know the bleeding precautions.

Independent: 1. Provide a soft toothbrush for oral hygiene.

2. Instruct the client to avoid blowing or picking the nose, straining at bowel

>To prevent bleeding of gums (Ref: page 2122 of Medical Surgical Nursing Vol. 2) > To avoid wound and bleeding. (Ref: page 2122 of Medical Surgical Nursing

movements, and avoid using razors. Men and women should use electric shavers during the neuropenic phase. 3. Avoid urinary catheters whenever possible. If a catheter must be inserted, use the smallest size possible, lubricate well and inserted gently. 4. Remove all potential hazards and sharps from the environment. Sharps corners or edges on furniture should be padded. 5. Avoid over inflation of the blood pressure cuff, and rotate the cuff to different sites.

Vol. 2)

>To avoid trauma and internal bleeding. (Ref: page 2122 of Medical Surgical Nursing Vol. 2)

>To prevent wound. (Ref: page 2123 of Medical Surgical Nursing Vol. 2)

> Because over inflation cant result internal bleeding to the client with leukemia.

(Ref: page 2122 of Medical Surgical Nursing Vol. 2) Subj >Client verbalized 7 out of 10 pain scale. Acute pain related to physical agents enlarged organs and lymph nodes, bone marrow packed with leukemic cells. Leukemias are cancers of the blood-forming tissues. White blood cells may be produced in excessive amounts and are unable to work properly which weakens the immune > After 8 hours When leukemia develops, of nursing intervention, the body produces large the client s vital numbers of abnormal signs will be monitored blood cells system. > Monitor clients
vital signs including: blood pressure, respiratory rate, pulse rate and temperature

After 8 hours of nursing intervention, the client s pain is relieved or controlled. Obj. > Vital signs are
an important component of physical therapy and examination of all patients. Knowledge of vital signs allows the therapist to understand a patients physiologic status and is helpful in determining appropriate goals. >Pain is a subjective experience and must be

The client s pain was relieved and controlled.

OBJ. > Bone pain >Headache >weakness >Irritability >Difficulty focusing and thinking >Guarding behaviour >Presence of Facial grimace when moving >Alteration in muscle tone Difficulty in sitting and standing

> The clients


vital signs were monitored

> After 8 hours of nursing intervention the

> Assess pain to


include location, characteristics, onset, duration,

> The client was able to verbalize the characteristic

client will be able to describe the characteristic and location of pain. > After 8 hours of nursing intervention the client will be able to perform pain management.

frequency, quality, intensity or severity and precipitating factors of pain.

described by the client in order to plan effective treatment.

and location of pain

> Teach the use


of nonpharmacologic techniques like deep breathing exercise

> The use of


non invasive pain relief measures can increase the release of endorphins and enhance the therapeutic effect of pain relief medications >Each client has a right to expect maximum pain relief. Optimal pain relief using analgesics includes determining the preferred route, drug, dosage and frequency for each individual

> The client was


able to perform deep breathing exercise and was able to take her due meds.

> After 8 hours of nursing intervention, the client s pain scale will be reduced.

> Provide
optimal pain relief with doctors prescribed analgesics.

>The clients pain was reduced.

SUBJECTIVE: I ve noticed that I bruise easily and also I feel weak and tired all the time, as verbalized by the patient. OBJECTIVE: y Irritability y Pallor of skin and mucous membranes y V/S taken as follows T: 37.1 P: 80 R: 19 BP: 100/80

Risk for infection related to inadequate primary defenses.

Leukemias are cancers of the blood-forming tissues. White blood cells may be produced in excessive amounts and are unable to work properly which weakens the immune system.

After 8 hours of Nursing intervention, the patient will identify actions to prevent or reduce the risk for infection. Objectives: y After 30 minutes of nursing intervention , the patient will verbalize understandi ng of individual causative/ris k factors.

After 8 hours of Nursing intervention, the patient was able to identify actions to prevent or reduce the risk for infection. y Inspect skin y for tender, erythematou s areas, open wounds. Cleanse skin with antibacterial solutions. Inspect oral mucous membranes. y May indicate local infection.

The oral cavity is an excellent medium for growth of organism and is susceptible to ulceration and bleeding.

After 4 hours of nursing intervention , the patient will be able to identify intervention s to prevent/red uce risk of infection.

Encourage frequent turning and deep breathing.

Prevents stasis of respiratory secretions, reducing risk of atelectasis or pneumonia. Prevents crosscontaminati on or reduce risk for infection. Protect patient from potential sources of pathogens or infection. Premature discontinua tion of treatment when client begins to feel well

Require good handwashin g protocol for all personnel and visitors. Limit visitors as indicated.

After 3 hours of nursing intervention , the patient will be able to promote

Emphasize necessity of taking antiviral or antibiotics.

wellness.

may result in return of infection and potentiate drugresistant strains.