Caring for a patient with Leukemia

General manifestations of leukemia regardless of type:

**anemia** pallor fatigue tachycardia malaise lethargy dyspnea bleeding **infection** fever night sweats oral ulceration respiratory/urinary/integement infection **Bleeding** result from thrombocytopenia bruising petechia bleeding gums

CHRONIC LYMPHOCYTIC LEUKEMIA (CLL) occurs:

+50

Assessment:

-Health history- Fatigue, weakness, dyspnea on exertion Frequent infections Weight loss -Physical examination- Bruising, purpura, pallor Vital signs, orthostatic vitals Heart and lung sounds

The nurse is assessing a client diagnosed with acute myeloid leukemia. which assessment data support this diagnosis? 1. fever and infection 2. nausea and vomiting 3. excessive energy and high platelet count 4. Cervical lymph node and positive acid-fast

1

client diagnosed with leukemia is scheduled for bone marrow transplantation. which interventions should be implemented to prepare the client for this procedure? 1. administer high-dose chemo 2. teach the client about autologous tranfusions 3. have the family members HLA typed 4. monitor for CBC daily 5. Provide central line care

1, 3, 4,5

Which of the following types of leukemia carries the best prognosis for children 1. ALL 2. AML 3. Basophilic leukemia 4. Eosinophilic Leukemia

1. ALL

What are the general types of leukemias:

1. Acute lymphocyctic (lymphoblastic) leukemia 2. Chronic lymphocytic leukemia 3. Acute myeloid (myeloblastic) leukemia 4. Chronic myeloid (myelogenous) leukemia

The nurse is caring for clients on an oncology unit. Which neutropenia precautions should be implemented? 1. hold all venipuncture sites 2. limit fresh fruits and flowers 3.have the client use a soft-bristle toothbrush 4. place all clients in reverse isolation

2

the client diagnosed with leukemia has CNS involvement. which instruction should the nurse teach? 1. sleep with the head of the bed elevated 2. take an analgesic medication for pain only when pain becomes severe 3. explain radiation therapy to the head may involve hair loss 4. discuss end of life decisions prior to cognitive deterioration

3

A nurse is caring for a patient with acute lymphoblastic leukemia (ALL). Which of the following is the most likely age range of the patient? A. 3-10 years. B. 25-35 years. C. 45-55 years. D. over 60 years.

A The peak incidence of ALL is at 4 years (range 3-10). It is uncommon after the mid-teen years. The peak incidence of chronic myelogenous leukemia (CML) is 45-55 years. The peak incidence of acute myelogenous leukemia (AML) occurs at 60 years. Two-thirds of cases of chronic lymphocytic leukemia (CLL) occur after 60 year

primarily affects children

ALL

Stem Cell Transplant

Allogeneic Stem cell transplant (SCT) is an alternative to BMT. SCT result in complete and sustained replacement of the recipient blood cell lines.

Graft vs Host Disease

Allogenic BMT or SCT may precipitate in GVHD, immune cells of the donated bone marrow identify the recipient's body tissue as foreign. Acute: develops within days or weeks of the transplant and is usually marked by a pruritic maculopapular rash that beings on the palms and soles of the feet & may extend over the entire body. Chronic: develops later (>100 days)

Which type of BMT uses the client's own bone marrow?

Autologous

A client with acute leukemia is admitted to the oncology unit. Which of the following would be most important for the nurse to inquire? a. "Have you noticed a change in sleeping habits recently?" b. "Have you had a respiratory infection in the last 6 months?" c. "Have you lost weight recently?" d. "Have you noticed changes in your alertness?"

B The client with leukemia is at risk for infection and has often had recurrent respiratory infections during the previous 6 months. Insomnolence, weight loss, and a decrease in alertness also occur in leukemia, but bleeding tendencies and infections are the primary clinical manifestations; therefore, answers A, C, and D are incorrect.

Ineffective Protection

Bleeding second most common cause of leukemia deaths Assess vital signs every 4 hours Assess body systems every shift for bleeding Avoid invasive procedures Apply pressure to injection sites 3-5 minutes, arterial punctures 15-20 minutes

A 33-year-old male is being evaluated for possible acute leukemia. Which of the following would the nurse inquire about as a part of the assessment? a. The client collects stamps as a hobby. b. The client recently lost his job as a postal worker. c. The client had radiation for treatment of Hodgkin's disease as a teenager. d. The client's brother had leukemia as a child.

C Radiation treatment for other types of cancer can result in leukemia. Some hobbies and occupations involving chemicals are linked to leukemia, but not the ones in these answers; therefore, answers A and B are incorrect. Answer D is incorrect because the incidence of leukemia is higher in twins than in siblings.

Diagnostic Test

CBC LOW RBC LOW PLATELET ELEVATED WBC Platelets Bone marrow examination

Evaluation

Client is adequately hydrated to allow elimination of drugs, cell components Client maintains normal urinary output Client remains free from infection Client's blood values maintained WNL Client demonstrates adequate knowledge related to disease process, treatment regimens

Plan

Client, family describe strategies to reduce risk of infection Client remains infection free Pediatric client meets developmental milestones Client expresses feelings related to diagnosis Client meets nutritional needs to maintain growth and/or weight Client reports symptoms of complications in a timely manner

Biologic Therapy

Cytokines, such as interferons and interluekins, are biologic agents that may be used to treat some leukemias. Side effects: flulike symptoms, fatigue, and lethargy, weight loss, muschle and joint pain.

Grieving

Discuss roles of client and family Use therapeutic communication skills to facilitate open discussion of losses Provide permission to grieve Provide information, referrals as indicated

allogeneic transplant place the client at risk for developing what complication?

Graft vs Host disease

CML Chemotherapeutic agents used:

Imatibin mesylate (Gleevec), a bcr/abl tyrosine kinase (enzyme) inhibitor, Hydroxyurea (a DNA inhibitor)or homoharringtonine (HHT, a plant alkaloid) if imatinib is not tolerated

The nurse is caring for a 2-year-old who has symptoms consistent with acute myelocytic leukemia and is in the hospital for diagnosis. When planning care for this child, the nurse offers which developmentally appropriate toy for diversion? Jigsaw puzzle Push-pull toy lawn mower Large picture books Pencil and paper to draw

Large picture books Rationale: Toddlers of this age typically enjoy looking at large picture books. While the push-pull toy is age-appropriate, symptoms of AML include fatigue and risk for bleeding, so this active toy would not be appropriate at this time. Pencil and paper and jigsaw puzzles are not age-appropriate for 2-year-olds.

CLL manifestations

Often diagnosed during routine physical fatigue malaise weakness anemia exercise intolerance lymphadenopathy splenomegaly recurrent infections pallor edema thrombophlebitis

In formulating a nursing diagnosis of risk for infection for a client with chronic lymphoid leukemia (CLL), nursing measures should include: (Select all that apply.) Maintaining a clean technique for all invasive procedures. Placing the client in protective isolation. Limiting visitors who have colds and infections. Ensuring meticulous handwashing by all persons coming in contact with the client.

Placing the client in protective isolation. Limiting visitors who have colds and infections. Ensuring meticulous handwashing by all persons coming in contact with the client.

Risk for infection

Promptly report manifestations of infection Institute infection protection measures Monitor vital signs Monitor neutrophil levels

ALL manifestations:

Recurrent infections bleeding anemia lymphadenopathy liver enlargment headaches vomiting seizures visual disturbances pallor bone pain weight loss sore throat fatigue night sweats weakness

Nursing Diagnosis

Risk for Infection Imbalanced Nutrition: Less Than Body Requirements Impaired Oral Mucous Membrane Ineffective Protection (Bleeding) Grieving

Imbalanced nutrition:

Weigh regularly Address causative or contributing factors to inadequate food, fluid intake Provide mouth care Increase liquid intake Provide medications as needed Small frequent meals Supplements

While caring for a client with leukemia, the nurse plans which of the following goals with the client? Will experience minimal bleeding Will manage self-care activities Will experience mild infections Will have no anxiety

Will manage self-care activities Rationale: The nurse teaches the client to pace activities so that self-care is manageable. The client should experience no infection and no bleeding. The client may continue to have anxiety, but the goal would be that it is decreased.

Define Leukemia

a group of chronic malignant disorders of WBCS and WBC precursors.

Leukemias are classified by their:

acuity and by the predominant cell type involved.

leukemias are classified by

cell type

Chronic Myeloid Leukemia (CML) characteristics

characterized by abnormal proliferation of all bone marrow elements; usually associated with a choromosome abnormality called Philadelphia Chromosome

Acute Leukemia characterized by:

characterized by an acute onset, rapid disease progression, and immature or undifferentiated blast cells

The treatment of choice for most types of leukemia is

chemotherapy

AML Chemotherapeutic agent:

cytarabine (Cytoxan, an alkylating agent) with Danunorubicin (Derubidine, an antitumor antibiotic) or idarubicin (Idamycin, an antitumor antibiotic); all-trans retinoic acid (ATRA) added for client with promyelocytic

CML manifestations

early stages: anemia (weakness, fatigue, dyspnea on exertion) possible splenomegaly Late Stage: fatigue weight loss sweating heat intolerance increased bruising ***Eventually evolves into acute leukemia***

Carry oxygen to the body tissues

erythrocytes

CLL chemotherapeutic agent

fludarabine (fludara, and antimetabolite) Chlorambucil (Chloromycetin, an antitumor antibiotic) Cyclophosphamide (Cytoxan, an alkylating agent) vincristine, and prednisone Cyclophosphamide, doxorubicin (Adraimycin, an antitumor antibiotic) vincristine and prednisoney

Chronic Luekemia characterized by:

gradual onset, prolonged course, and abnormal mature-appearing cells.

the production of blood cells

hemopoiesis

a group of chronic malignant disorders of the blood-forming tissues;

leukemia

help the body fight infections

leukocytes

CLL treatment

often requires no treatment;chemotherapy, BMT

AML common in

older adults strongly associated with toxins, genetic disorder, and treatment of other cancers

Lymphocytic leukemias infiltrate:

spleen, lymph nodes, CNS,

A client with acute myelocytic leukemia (AML) is scheduled for a bone marrow transplant (BMT). In reinforcing client and family teaching about BMT, which of the following statements by the nurse is best? "The client will be in the operating room with the donor so that immediate transplantation can occur." "The client will be brought to the radiation department to transplant the marrow." "The specially prepared marrow is infused intravenously to the client." "A large bore needle will be inserted into the client's bone marrow where the donor marrow will be infused."

"The specially prepared marrow is infused intravenously to the client." Rationale: Harvested bone marrow is infused in the client intravenously. The transplantation is usually preceded by chemotherapy and radiation therapy. The other options are incorrect procedure.

the client is diagnosed with CLL after routine lab tests during yearly physical. which is the scientific rationale for the random nautre of discovering the illness 1. CLL is not serious, and clients die from other causes first 2. there are no symptoms with this form of leukemia 3. this is a childhood illness 4. in early stages, CLL may be asymptomatic

4

The nurse caring for a client with acute myelocytic leukemia (AML) plans which of the following nursing interventions during hospitalization? (Select all that apply.) Place in a private room. Assist with oral hygiene after meals. Request soft, bland diet. Implement airborne infection control precautions. Monitor rectal temperature every 4 hours.

Assist with oral hygiene after meals. Request soft, bland diet. Place in a private room. Rationale: AML causes both neutropenia and thrombocytopenia, with resulting risk for infection and bleeding. A private room and oral hygiene reduce infection risk, and a soft, bland diet reduces trauma to oral mucosal membranes. Leukemia is not communicable; airborne infection control measures are unnecessary. Rectal temperatures are avoided to protect rectal mucosa integrity.

patient receiving chemotherapy for acute lymphocytic leukemia has pancytopenia, and filgrastim (Neupogen) is prescribed. The nurse teaches the patient that the reason for the use of the medication is a. to help promote remission of the acute leukemia. b. to improve the number and function of neutrophils. c. replacement of abnormal stem cells in the bone marrow with normal cells. d. prevention of hemorrhage complications in patients with thrombocytopenia.

B Rationale: Filgrastim increases the neutrophil count and function in neutropenic patients. It does not cause remission of the leukemia or cause changes in the bone marrow stem cells. Thrombocytopenic patients may receive oprelvekin (Neumega) to increase platelet count and decrease bleeding risk.

Which of the following would be the priority nursing diagnosis for the adult client with acute leukemia? a. Oral mucous membrane, altered related to chemotherapy b. Risk for injury related to thrombocytopenia c. Fatigue related to the disease process d. Interrupted family processes related to life-threatening illness of a family member

B The client with acute leukemia has bleeding tendencies due to decreased platelet counts, and any injury would exacerbate the problem. The client would require close monitoring for hemorrhage, which is of higher priority than the diagnoses in answers A, C, and D, which are incorrect.

Where blood cells are formed?

Bone Marrow

A patient with newly diagnosed leukemia is receiving chemotherapy. Which intervention will the nurse include in the plan of care? a. Avoid the intake of fresh fruits and vegetables. b. Administer oral prophylactic antibiotics. c. Teach visitors hand washing techniques. d. Place the patient in a laminar airflow room.

C Rationale: Infection-control measures such as handwashing are necessary for the patient receiving chemotherapy. Restrictions of fresh fruits and vegetables, prophylactic antibiotics, and laminar airflow rooms are used for patients who are neutropenic, but not for all patients receiving chemotherapy.

Etiology

Diagnosed 10x more in adults Genetic factors: Down Syndrome Ionizing radiation when in utero and chemical agents from early cancer treatment

Risk Factors

Men are affected more frequently than women People with certain genetic disorders:Down Syndrome Risk factor for myeloid leukemia include cigarette smoking

ALL pathophysiology:

Most cases result form malignant transformation of B cells with the remaining arising from T cells; Malignant cells resemble immature lymphocytes that do not mature or function effectively to maintain immunity; most common in children.

All types of blood cells develop from this:

Stem cell

ALL Treatment

chemotherapy BMT SCT

How is leukemia characterized?

leukemias are characterized by replacement of bone marrow by malignant immature WBCs, abnormal immature circulating WBCs, and infiltration of these cells into the liver, spleen, and lymph nodes throughout the body.

In general, in the bone marrow:

malignant WBCs rapidly fill the bone marrow, replacing stem cells that produce erythrocytes & other blood products, such as platelets, thereby decreasing the amount of these products in circulation. the stem cells are replaced by leukemic clones, eventually resulting in anemia and abnormally bleeding because of decreased platelets.

Acute Lymphoblastic Leukemia (ALL) characteristics:

primarily affects children and young adults; leukemic cells may infiltrate the CNS

ALL onset:

rapid lymphoblast proliferating in bone marrow and peripheral tissues crowd the growth of normal cells

help form blood clots

thrombocytes

the exact cause of leukemia is

unknown

Allogeneic BMT

uses bone marrow cells from a donor (often from a sibling with closely matched tissue antigen) **high doses of chemotherapy and/or total body irradiation are used to destroy leukemic cells in the bone marrow. The bone marrow is aspirated and infused through a central venous line into the recipient** *Risk for infection and bleeding because of decreased WBCs & platelets*

Autologous BMT

uses the client's own bone marrow to restore bone marrow function after chemotherapy or radiation bone marrow is aspirated during periods of remission and freezed and stored. if relapse occurs,lethal doses of chemotherapy or radiation are given to destroy the immune system and malignant cells and to prepare space in the bone marrow for new cells.

A client with leukemia has developed stomatitis and is on neutropenic precautions. Mouthwash every two hours has been ordered for the client. The nurse would question which of the following if ordered by the physician? Diluted baking soda Hydrogen peroxide Viscous lidocaine (Xylocaine) Normal saline solution

Hydrogen peroxide Rationale: Hydrogen peroxide has a tendency to cause dryness in the oral mucosa and further aggravate the condition. The other three options are all acceptable to use for the client with leukemia.

Most common type of leukemia in adults

acute myeloid leukemia chronic lymphocytic leukemia

Leukemias can be either:

acute or chronic

Bone Marrow Transplant (BMT) Categories

allogeneic Autologous

general manifestations of leukemia

anemia

How is GVHD treated?

antibiotics and steroids immunosuppressants

A child with leukemia who is being treated with chemotherapy is visited by a grandmother who has brought flowers from her garden for the child. Which of the following is the appropriate response by the nurse? "Let me wash your vase before we put flowers in it." "Place the flowers across the room from the child." "I will get a vase for you." "The flowers are beautiful, but the child cannot have them right now."

"The flowers are beautiful, but the child cannot have them right now." Rationale: For the child with neutropenia subsequent to chemotherapy, flowers and plants in the room put the child at risk for aspergillus and pseudomonas infections. Washing the vase or providing one from the unit does not provide adequate protection. Flowers and plants should not be present in a unit that is caring for neutropenic clients.

What are the needs of the patient with acute lymphocytic leukemia and thrombocytopenia? (A) to a private room so she will not infect other patients and health care workers — (B) to a private room so she will not be infected by other patients and health care workers — (C) to a semiprivate room so she will have stimulation during her hospitalization — (D) to a semiprivate room so she will have the opportunity to express her feelings about her illness —

(B) to a private room so she will not be infected by other patients and health care workers — CORRECT: protects patient from exogenous bacteria, risk for developing infection from others due to depressed WBC count, alters ability to fight infection

ACUTE MYELOID LEUKEMIA (AML) occurs:

AML IS USUALLY DISEASE THAT OCCUR IN OLDER ADULTS.

CHRONIC MYELOID LEUKEMIA (CML) occurs:

CML OCCURS IN ADULTS OVER 50 YRS. OLD

An African American client is admitted with acute leukemia. The nurse is assessing for signs and symptoms of bleeding. Where is the best site for examining for the presence of petechiae? a. The abdomen b. The thorax c. The earlobes d. The soles of the feet

D. Petechiae are not usually visualized on dark skin. The soles of the feet and palms of the hand provide a lighter surface for assessing the client for petichiae. Answers A, B, and C are incorrect because the skin might be too dark to make an assessment.

Leukemia can develop at any point during cell

Differentiation

The nurse is caring for a client who is in the hospital for diagnostic testing. On physical assessment, the nurse notes an enlarged spleen, oral ulcerations, and a decreased level of consciousness. Which of the following laboratory results would the nurse anticipate for this client? Hypocalcemia Increased white blood cell count Increased platelets Hyperkalemia

Increased white blood cell count Rationale: The client exhibits signs of leukemia, and the nurse would anticipate a high white blood cell count. Calcium levels would not necessarily be affected. Platelets would decrease and potassium levels would probably be normal.

Acute Myeloid Leukemia (AML) characterized by:

abnormal proliferation of myeloblasts and hyperplasia of bone marrow and spleen.

what is the most common type of leukemia in children

acute lymphoblastic leukemia

Chronic Myeloid Leukemia (CML) primarily affects:

adults; early course slow and stable, progressing to aggressive phase in 3-4 years

Chronic lymphocytic leukemia characteristic

characterized by proliferation and accumulation of small, abnormal, mature lymphocytes in the bone marrow, peripheral blood and body tissues abnormal cells are usually B lymphocytes that are unable to produce adequate antibodies to maintain normal immune function affects older adults; insidious onset and slow, chronic course

AML treatment

chemotherapy, SCT

AML manifestations?

manifestations result from neutropenia and thrombocytopenia; include severe infections (pneumonia, septicemia, abscesses, and mucous membrane ulceration) petechia purpura ecchymosis hematomas epistaxis bone infarctions GI bleeding bone pain anemia (headache, fatigue, pallor, dyspnea on exertion)

ALL Chemotherapeutic agent

daunorubicin (Cerubidine, an antitumor antibiotic) with Vincristine (Oncovin, a plant alkaloid) with prednisone with asparaginase.

Lymphocytic or lymphoblastic leukemias involve:

immature lymphocytes and their precursors cells in the bone marrow.

ACUTE LYMPHOCYTIC LEUKEMIA (ALL) occurs:

in children

CML treatment

interferon alpha Chemotherapy SCT

What nursing diagnosis is seen with acute lymphocytic leukemia and thromocytopenia? A) Potential for injury (B) Self-care deficit (C) Potential for self-harm (D) Alteration in comfort

A) Potential for injury — CORRECT: low platelet increases risk of bleeding from even minor injuries. Safety measures: shave with an electric razor, use soft tooth brush, avoid SQ or IM meds and invasive procedures (urinary drainage catheter or a nasogastric tube), side-rails up, remove sharp objects, frequently assess for signs of bleeding, bruising, hemorrhage.

Myeloid involve:

myeloid stem cells in the bone marrow, interfering with the maturation of all types of blood cells, including granulocytes, RBCs, and thrombocytes.

In Leukemia, what is reversed?

the usual ratio of RBCs to WBC is reversed.

A 45-year-old patient with chronic myelogenous leukemia (CML) is considering the possibility of treatment with a hematopoietic stem cell transplant (HSCT) from an HLA-matched sibling. To assist the patient with treatment decisions, the best approach for the nurse to use is to a. emphasize the positive outcomes of a bone marrow transplant. b. ask the patient whether there are any questions or concerns about HSCT. c. explain that a cure is not possible with any other treatment except HSCT. d. discuss the need for adequate insurance to cover post-HSCT care.

B Rationale: Offering the patient an opportunity to ask questions or discuss concerns about HSCT will encourage the patient to voice concerns about this treatment and will also allow the nurse to assess whether the patient needs more information about the procedure. Treatment of CML using chemotherapy is another option for the patient. It is not appropriate for the nurse to ask the patient to consider insurance needs in making this decision.

A patient is undergoing the induction stage of treatment for leukemia. The nurse teaches family members about infectious precautions. Which of the following statements by family members indicates that the family needs more education? A. We will bring in books and magazines for entertainment. B. We will bring in personal care items for comfort. C. We will bring in fresh flowers to brighten the room. D. We will bring in family pictures and get well cards.

C During induction chemotherapy, the leukemia patient is severely immunocompromised and at risk of serious infection. Fresh flowers, fruit, and plants can carry microbes and should be avoided. Books, pictures, and other personal items can be cleaned with antimicrobials before being brought into the room to minimize the risk of contamination.

A patient with chronic lymphocytic leukemia is hospitalized for treatment of severe hemolytic anemia. An appropriate nursing intervention for the patient is to a. provide a diet high in vitamin K. b. isolate the patient from visitors. c. plan care to alternate periods of rest and activity. d. encourage increased intake of fluid and fiber in the diet.

C Rationale: Nursing care for patients with anemia should alternate periods of rest and activity to maintain patient mobility without causing undue fatigue. High vitamin K diets might be used for a patient with a bleeding disorder. There is no indication that the patient is neutropenic, so isolation is not needed. Increased intake of fluid and fiber will not improve the anemia.

A 64-year-old patient with newly diagnosed acute myelogenous leukemia (AML) who is undergoing induction therapy with chemotherapeutic agents tells the nurse, "I feel so sick that I don't know if the treatment is worth completing." The nurse's best response to the patient is a. "I know you feel really ill right now, but after this therapy your disease will go into a remission and you will feel normal again." b. "Induction therapy is very aggressive and causes the most side effects, so when this phase is completed you won't feel so ill." c. "Your type of leukemia has an 80% survival rate if aggressive therapy is started, so the effects of treatment will be worth it to you." d. "The chemotherapy is difficult, but it is necessary to put the disease into remission and give you time to make choices about your life."

D Rationale: AML is very aggressive, and survival after diagnosis is short without treatment. Induction therapy is followed by more chemotherapy, so the nurse should not tell the patient that he or she will feel normal or not so ill. The survival with AML is not 80%.

Which of the following nursing diagnoses would be of highest priority for a client hospitalized for a bone marrow transplant to treat relapse of acute myelocytic leukemia? Imbalanced Nutrition: Less than Body Requirements Anxiety Ineffective Protection Disturbed Body Image

Ineffective Protection Rationale: Prior to bone marrow transplant, chemotherapy or total body irradiation is used to destroy leukemic cells in the bone marrow. Normal blood cells are also destroyed, causing significant risk for infection and bleeding. The other diagnoses, while appropriate, are of lower priority.

Impaired Oral Mucous Membrane

Inspect buccal region Culture oral lesions Assist with mouth care Encourage use of soft bristle toothbrush Administer medications as ordered Instruct client to avoid alcohol-based mouthwashes, citrus juices, spicy or crusty foods

Leukemia: What went wrong?

Replacement of bone marrow by abnormal cells results in unregulated proliferation of immature WBCs entering the circulatory system. these leukemic cells may also enter the liver, spleen, or lymph nodes, causing these areas to enlarge. Leukemia is classified according to the type of cell it is derived from, lymphocytic, or myelocyctic, and as either acute or chronic. Lymphocytic leukemias involve immature lymphocytes originating in the bone marrow and typically infiltrating the spleen, lymph nodes, or cns. Myelogenous or myelocytic leukemia involves the myeloid stem cells in the bone marrow and interferes with the maturation of all blood cell types The exact cause is unknown