Download Leukemias

Leukemias
It is a malignant disorder involving bone marrow dysfunction manifested
by anemia, thrombocytopenia, and abnormal proliferation of white cells, which
results in harmful filtration into tissues. It is the most common malignancy in
childhood (30%), peak incidence 2-8 years of age. Incidence among males is
greater than females’ 2:1.
Etiology:
Although the exact cause is unknown, but multiple factors believed to be
responsible: ionizing radiation, chemicals (benzene compound, heavy
metals), drugs (Alkylating agents), and chromosomal abnormalities (Down
syndrome), and familial predisposition.
Pathophysiology:
There will be a bone marrow failure resulted from overgrowth of
leukemic cells in the marrow (immature blast cells).
Both red cells precursors and megakaryocytes from which platelets are
formed are decreased leading to anemia and epistaxis, and easy bruisability.
 Since white blood cells are decreased infection is common.
 Leukemic cells will proliferate (migrate out) of bone marrow and
infiltrate in lymph nodes spleen, liver leads to Hepato-splenomegaly
and lymphoadenopathy.
Classification:
Leukemia is classified according to its predominant cell type and level of
maturity as described by the following:
 Lympho
for Leukemias involving the lymphoid or lymphatic
system.
 Myelo
for those of myeloid (bone marrow) origin.
 Blastic and acute
for those involving immature cells.
 Cytic and chronic
for those involving mature cells.
In children two forms are generally recognized:
 Acute lymphoid leukemia (A.L.L.) and acute nonlymphoid leukemia
(A.N.L.L) or (A.M.L).
 A.L.L includes lymphatic, lymphocytic, lymphoblastic and
lymphoblastoid leukemia.
 A.N.L.L. type includes granulocytic, myelocytic, monocytic,
myelogenous, monoblastic and monomyeloblastic.
Assessment:
It is according to the pathological effect:
Organ or Tissue
Consequences
1. Decreased RBCs
Bone
Marrow
anemia.
Dysfunction
2. Neutropneia
infection.
3. Decreased
platelets
bleeding tendancy.
4. Invasion of bone marrow
bone weakness.
5. Invasion of periosteum
increase pressure.
1. Infiltration.
Liver, Spleen and 2. Enlargement.
Lymph gland
3. Eventual fibrosis.
1. Increased
intracranial
CNS Meninges
pressure.
Manifestation
Pallor,
exertion.
Fever
fatigue,
dyspnea
Hemorrhage
(Petechia)
Tendency toward fractures.
Pain (pain in joint, episodes of
abdominal pain)
1. Hepatomegaly.
2. Splenomegaly.
3. Lymphoadenopathy.
1. Severe headache.
2. Vomiting.
3. Irritability.
2. Ventricular enlargement.
4. Lethargy.
5. Papilledema.
6. Eventual coma.
3. Meningeal irritation.
7. Pain.
8. Stiff neck and back.
1. Cell deprivation of nutrients 1. Lassitude.
Hypermetabolism
by invading cells.
2. Muscle wasting.
3. Weight loss.
4. Anorexia.
5. Fatigue.
6. Low-grade fever.
Diagnostic Evaluation:
Leukemia is usually suspected by the history, physical manifestations
and peripheral blood smear that contains immature forms of leukocytes,
frequently combined with low blood counts. Definitive diagnosis is based on
bone marrow is hypercellular with primarily blast cells. Once the diagnosis is
confirmed, a lumber puncture is performed to determine if there is any C.N.S.
involvement.
Therapeutic Management:
Treatment of leukemia involves the use of chemotherapeutic agents with
or without irradiation in three phases:
1. Remission induction therapy: which is determined by the absence of
clinical evidence of disease and the presence of less than 5% blast
cells in the bone marrow.
2. C.N.S. preventive therapy and consolidation, which provides
treatment in those areas of the body normally protected from cytotoxic,
drug levels.
3. Maintenance therapy, which serves to maintain the remission phase.
In some children a fourth phase, reinduction therapy is needed to treat
a relapse.
1. Remission Induction:
(Eradicate leukemic cells)
Almost immediately after confirmation of the diagnosis, induction
therapy is begun and lasts 4 to6 weeks. The principal drugs used for induction
in A.L.L. are:
 Corticosteroids. (Especially Prednisone).
 Vincrisline Sulfate “ Oncovin”.
 Adramycin.
2.C.N.S. preventive therapy / Consolidation:
(Prevention
of
meningeal
leukemia)
Treatment of the C.N.S consists of prophylactic therapy with intrathecal
chemotherapy. This therapy is reserved for high-risk patients and those with
C.N.S. disease. C.N.S. therapy usually begins during the first 6 to 8 weeks
after diagnosis and is continued for a specific period of time.
Once complete remission is obtained, a period of intensified treatment is
administered to further reduce the leukemia burden (Consolidation).
3.Maintenance therapy:
Maintenance therapy is begun after completion of successful induction
and consolidation therapy to preserve the remission and further lessen the
number of leukemic cells.
4.Reinduction therapy: (Fourth phase)
When the presence of leukemic cells are observed in the bone marrow,
C.N.S. or other sites, the child has relapsed. Therapy for the child who has
relapsed includes reinduction. Other drugs not previously used.
Bone marrow transplantation:
It has been used successfully for treating children who have A.L.L.. and
A.N.L.L. bone marrow transplantation is not recommended for children with
A.L.L. during the first remission because of the excellent results possible with
chemotherapy. Because of the poor prognosis in children with A.N.L.L.
transplantation may be considered during the first remission.
Prognosis:
The most important factors for determining long-term survival for
children with A.L.L. in addition to treatment are:
1. The initial WBCs count.
2. The child’s age at the time of diagnosis.
3. The type of cell involved.
4. The sex of the child.
Children diagnosed between 2 and 9 years of age have consistency
demonstrated a better outlook than those diagnosed before 2 or after
10 years of age, and females appear to have a more favorable
prognosis than male.
Nursing care plan for the child with leukemia:
Nursing diagnosis:
1. High risk for infection related to depressed body defenses.
Goal:
Patient will experience minimized risk of infection.
Intervention:







Place child in private room.
Advise all visitors and staff to practice hand washing.
Screen all visitors and staff for signs of infection.
Use aseptic technique.
Evaluate child for any potential sites or infections.
Provide nutritionally complete diet for age.
Administer antibiotics as prescribed.
Expected Outcome:
 Child doesn’t come in contact with infected persons or contaminated
articles.
 Child consumes diet appropriate for age.
Nursing diagnosis:
2. High risk for injury (hemorrhage) related to interference with cell
proliferation.
Goal:
Patient will exhibit no evidence of bleeding.
Intervention:
 Use all measures to prevent infection, especially in ecchymotic area.
 Use local measures to stop bleeding.
 Restrict strenuous activity that could result in accidental injury.
 Involve child in responsibility for limiting activity when platelet count
drops.

Administer platelets as prescribed.
Expected Outcome:

Child exhibits no evidence of bleeding.
Nursing diagnosis:
3. Altered nutrition less than body requirement related to loss of appetite.
Goal:
Patient will receive adequate nutrition.
Intervention:
 Encourage parents to relax pressure placed on eating.
 Allow child any food tolerated. Improve quality of food selections
when appetite increases.
 Stress expected increase in appetite from steroid.
 Take advantage of any hungry period, sever small snakes.
 Allow child to be involved in food preparation and selection.
 Make food appealing.
 Remember usual food practices of children in each age group.
Expected Outcome:

Nutrition intake is adequate.
Nursing diagnosis:
4. High risk for fluid volume deficit related to nausea and vomiting.
Goal:
Patient will experience no vomiting.
Intervention:
 Administer initial dose of antiememtic before onset of nausea and
vomiting.
 Avoid foods with strong odors.
 Uncover hospital food tray outside of child’s room to reduce food
orders.
 Mouths care frequently.
Expected Outcome:

Child retains food and fluids.
Nursing diagnosis:
5. Altered mucous membranes related to administration of chemotherapeutic
agents.
Goal:
Patient will not develop oral mucostis.
Intervention:


Inspect mouth daily for oral ulcers, avoid oral temperatures.
Oral hygiene as soon as a drug is used that caused oral ulcers.
 Use soft sponge toothbrush, cotton tipped applicator or gauze
wrapped finger.
 Administer frequent (at least every 4 hours and after meals)
mouthwashes (normal saline or sodium bicarbonate solution).
 Apply local anesthetics to ulcerated areas before meals and as
needed.
 Serve bland, moist, soft diet.
 Encourage fluids; use a straw to help bypass painful areas.
 Report evidence of ulcers to doctor.
 Avoid juices containing ascorbic acid lemon swabs and hot or cold
food.
 Administer antiinfective medication as ordered.
Expected Outcome:


Mucous membrane remains intact.
Ulcer shows evidence of healing.
Goal: (2)
Patient will not develop rectal ulceration.
Intervention:
 Wash perineal area after each bowel movement.
 Use warm bath or tub baths.
 Apply protective skin barriers (transparent film dressings, occlusive
ointment) to perineal area.
 Observe constipation resulting from child’s voluntary refusal to
defecate or from chemotherapy.
 Avoid rectal temperature and suppositories.
 Record bowel movement, use stool softener to prevent constipation.
Expected Outcome:



Rectal mucosa remains clean and intact.
Ulcerated areas heal without complications.
Child has regular bowel movements.
Nursing diagnosis:
6. Impaired skin integrity related to administration of chemotherapeutic
agents.
Goal:
Patient will maintain skin integrity.
Intervention:



Provide skin care especially in mouth and perineal regions.
Change position frequently.
Encourage adequate caloric-protein intake.
Expected Outcome:

Skin remains intact.
Nursing diagnosis:
7. Pain related to diagnosis and treatment.
Goal:
Patient will experience minimal or no pain.
Intervention:
 Avoid excessive noise or light.
 Place all commodities with easy reach.
 Use gentle, minimal physical manipulation.
 Avoid pressure on painful relief from analgesics.
 Experiment with using heat or cold on painful areas (Use cautiously
because of easy skin breakdown).
 Change position frequently, if difficult for child coordinate with pain
relief from analgesics.
 Avoid pressure on bony prominences.
 Administer analgesics as prescribed.
 Avoid aspirin or any of its compounds.
Expected Outcome
 Child rests quietly, exhibits no evidence of discomfort verbalizes no
complaints of discomfort.
Nursing diagnosis:
8. Body image disturbance related to loss of hair and moon face.
Goal: (1)
Patient will exhibit positive coping.
Intervention:
 Administer good scalp hygiene.
 Provide adequate covering during exposure to sunlight, wind or cold.
 Stress that hair begins to regrow in 3 to 6 months and may be a
slightly different color or texture.
Expected Outcome:


Child verbalizes concern regarding hair loss.
Child appears clean, well groomed and attractively dressed.
Goal: (2)
Patient will exhibit adjustment to altered facial appearance.
Intervention:



Stress that this reaction is temporary.
Evaluate weight gain carefully.
Encourage early and consistent interaction with peer.
Expected Outcome:

Child resumes former activities and relationship within capabilities.
Nursing diagnosis:
9. Fear related to diagnostic tests, procedures, treatment, and prognosis.
Goal:
Patient will exhibit reduced fear related to diagnostic procedures and
tests.
Intervention:
 Explain procedure carefully at child’s level of understanding.
 Explain responsibility of child.
 Provide child with some means of involvement with the procedure.
 Implement distracting technique and pain reduction techniques as
indicated.
Expected Outcome:


Child readily responds to verbal directives and exhibits less fear.
Child repeats information accurately.
Nursing diagnosis:
10. Altered family process related to a child with life threatening disease.
Goal:
Family will receive adequate support.
Intervention:
 Teach parents about disease process.
 Explain all procedures that will be done to child.
 Schedule time for family to be together.
 Help family for future, especially toward helping child live a normal
life.
 Encourage family to discuss feelings regarding child’s course prior to
diagnosis and child’s prospects for survival.
 Discuss with family how they will tell child about outcome of the
disease.
Expected Outcome:
Family expresses feelings and concerns and spends time with child