s

Acute Lymphocytic Leukemia

Definition
A rapidly progressing form of leukemia that is characterized by the neoplastic proliferation of the leukocytes and their precursors.It involves the bloodforming tissues of the bone marrow, spleen and lymph nodes.

Blood Cell Maturation

Etiology
y Occurs when a bone marrow cell develop error in its

DNA. This error then tells the cell to continue growing and dividing causing the bone marrow to continuously produce immature cells that develops into leukemic lymphoblasts. These cells are unable to function properly and they can build up and crowd out healthy cells.

Cell Proliferation

Risk Factors
y Children (most common among men than women

with a peak incidence between 2-5 years of age) y Exposure to radiation, chemicals/drugs, viruses y Certain genetic disorders (Down Syndrome, Klinefelter Syndrome)

Pathophysiology
y C:\Documents and

Settings\Arjay\Desktop\ALL\Pathophysiology of Acute Lymphocytic Leukemia.doc

Diagnostic Evaluation
1. Blood tests
y A blood test may reveal reduced numbers of

erythrocytes and platelets. Leukocytes may either be high or low, but there is always a high proportion of immature cells.
y y

Explain the procedure to the patient After the procedure, observe for the site for any reaction

Diagnostic Evaluation
2. Bone Marrow test
y A needle is used to remove a sample of bone marrow to

look for leukemia cells. Sample will be classified into specific cell types based on their size, shape and other features and to observe for changes in blood cells.
y y y

Check for the signed informed consent Help relieve anxiety by explaining the procedure to the patient During the actual aspiration, deep breaths may help the patient relieve pain felt After the procedure, patient will be on lying position and is observed for bleeding for one hour Monitor patient s vital signs after the procedure

Diagnostic Evaluation
3. Imaging Test (CT scan)
y It helps determine whether cancer has spread to other

parts of the body.

y y y y y

Remove any metal objects Check for informed consent if contrast agent will be used If with contrast agent, check for patient s allergies Assess for phobia to enclosed spaces or claustrophobia Help relieve patient s anxiety by explaining the procedure

Drug Analysis
y ALL Report\drugs final(all).doc

Nursing Management
y Provide comfort to the patient. y Have a clean and neat environment. y Explain that chemotherapy may cause weight loss and

hair loss. y Encourage the patient to eat a diet high calories and protein.

Nursing Management
y If patient have a oral lesions, teach the patient to use

soft tooth brush or cloth, and to avoid hot, spicy foods, and commercial mouthwashes, which can irritates mouth ulcers. y Encourage the patient to take frequent rest periods during the day and to space activities with rest. y Encourage to drink atleast 2000ml of fluids per day.

Nursing Management
y Preventing infection: y Monitor for fever, flushed appearance, chills, tachycardia; appearance of white patches in the mouth, cough, abdominal pain, skin rash. y Avoid invasive procedures and trauma to skin or mucous membrane to prevent entry of microorganisms. y Use the following rectal precautions to prevent infections: Avoid diarrhea and constipation, which can irritate the rectal mucosa, avoid the use of rectal thermometers, and keep perineal are clean.

Nursing Management
y Care for the patient in private room with strict

handwashing practice. y Encourage and assist patient with personal hygiene, bathing, and oral care. y Obtain cultures and administer antimicrobials promptly as directed.

Nursing Management
y Preventing and Managing bleeding: y Watch for signs of minor bleeding, such as petechiae, ecchymosis, conjunctival hemorrhage, epistaxis, bleeding gums, bleeding at puncture sites, vaginal spotting, heavy menses. y Test all urine, stool, emesis for gross and occult blood. y Monitor platelet counts daily. y Administer blood components as directed. y Keep patient on bed rest during bleeding episodes.

Nursing Management
y Patient Education and Health Maintenance: y Teach signs and symptoms of infection and advise whom to notify. y Encourage adequate nutrition to prevent emaciation from chemotherapy. y Teach avoidance of constipation with increased fluid and fiber, and good perineal care. y Encourage regular dental visits to detect and treat dental infections and disease.

Medical- Surgical Management

1. Chemotherapy y This is the treatment choice of most types of leukemia, with a goal of eradicating leukemic cells and producing remission. Children with this disease are likely to be cured and a number of adult patients have high remissions.

Medical- Surgical Management

y Chemotherapy treatment can be divided into four

phases:
y First phase

induction chemotherapy y Second phase consolidation chemotherapy y Third phase maintenance chemotherapy y Fourth phase central nervous system (CNS) prophylaxis

Medical- Surgical Management

a. Induction Chemotherapy
y The induction chemotherapy is done in the hospital and

most patients need to be in the hospital for approximately four weeks. y Most common drugs used in the treatment of ALL are:
y y y y

Daunorubin (cerubidine, an antitumor antibiotic) Vincristine (oncovin, a plant alkaloid) Prednisone Asparaginase (elspar).

Medical- Surgical Management

y Induction treatment for ALL is somewhat more gentle than y y

that for AML. Intensive supportive care is still needed including transfusion of red blood cells and platelets. Although the likelihood of mouth sores and disruption of the intestinal tract is rare, complete but temporary hair loss does occur. Once blood counts have returned to normal, a repeat bone marrow biopsy is performed to determine whether the patient has entered complete remission. A complete remission is achieved when the blood and bone marrow show no evidence of persistent leukemia and blood counts have returned to normal.

Medical- Surgical Management

b. Consolidation Chemotherapy
y Includes multiple cycles of intensive chemotherapy

given over a six- to nine-month period. y Frequent hospitalizations are required and intensive supportive care is still needed, including red blood cell and platelet transfusions. y Stem cell transplantation is not typically performed to treat ALL unless abnormal cytogenetics are present. y Chemotherapy agents used during consolidation include the same agents used during induction, as well as Ara-C, etoposide, methotrexate and 6-mercaptopurine.

Medical- Surgical Management

c. Maintenance Chemotherapy
y Once patients have completed intensive chemotherapy,

they need to take oral chemotherapy pills for an additional 18 to 24 months. y These oral chemotherapy pills typically methotrexate and 6-mercaptopurine are usually well-tolerated with only minimal side effects. y Patients need to have their blood tests checked once a month while taking chemotherapy pills. y Most patients with ALL can return to work during maintenance therapy.

Medical- Surgical Management

d. Central Nervous System (CNS) Prophylaxis
y ALL frequently can recur in the spinal fluid, the fluid

that bathes the spinal column and brain. To prevent relapse at this location, chemotherapy must be injected directly into the fluid that bathes the spinal column. y This is done by inserting a needle between the vertebrae of the lower back called a spinal tap or lumbar puncture and infusing chemotherapy directly into the clear spinal fluid. This is called intrathecal chemotherapy.

Medical- Surgical Management

y Patients are routinely given six or more injections of

intrathecal chemotherapy to prevent recurrence of ALL. y More injections may be necessary if leukemia cells are detected in the spinal fluid. y Most people complete intrathecal therapy within two to four months of starting their treatment. y Headaches and nausea are occasional side effects.

Medical- Surgical Management

2. Radiation Therapy (Radiotherapy)
y Uses high-energy rays to kill leukemia cells.

Radiotherapy damages cellular DNA. Though the leukemic cells continue to function, it cannot divide and multiply y Radiotherapy is also aimed at the spleen, the brain, or other parts of the body where leukemia cells have collected.

Medical- Surgical Management

3. Bone Marrow Transplant (BMT)
y This is often used in conjunction with chemotherapy or

radiation. There are 2 categories:

a. Allogenic BMT
y Uses the bone marrow of a healthy donor (usually from a

sibling/unrelated closed matched antigen. The donor s bone marrow is aspirated and is infused through a central venous line into the recipient.

Medical- Surgical Management

b. Autologous BMT (or bone marrow rescue) y Uses the client own bone marrow to restore the bone marrow function after chemotherapy or radiation. During the period of disease remission, about 1L of bone marrow is aspirated from the patient. It is then stored and frozen for use after treatment of chemotherapy or radiation, with the aim of destroying the immune system and malignant cells and to prepare space in the bone marrow for new cells. The filtered bone marrow is thawed and infused intravenously through central line and slowly become part of the client s bone marrow, neutrophil count increases, and normal haematopoiesis takes place.

Medical- Surgical Management

4. Allogeneic Stem Cell Transplant
y Is a replacement of the recipients blood cell lines

(WBCs, RBCs, and platelets) with cells derived from the donor stem cells. This is an alternative to bone marrow transplant. The recipient and the donor tissue must be closely matched prior to harvesting and necessary procedure and treatment are conducted prior to harvesting to prevent the risk of infection and other complications.

Nursing Care Plan

y ALL\NCP.doc