LEUKEMIA

Definition

The leukemia – Are neoplastic disorders of the blood forming tissues (spleen, lymphatic system and bone marrow).

They are characterized by wide spread proliferation within the bone marrow and other blood forming tissues of immature of one of the leucocytes. The process reduces production of other constituent of normal blood e.g no enough R.B.C, platelets etc, thus leading to hemorrhages and anemia. The bone marrow is over crowded by W.B.C.

Causes

Unknown

Classifications

Classified according to: -

1. The cells involved lymphocyte, granulocytic or monocytic
2. The maturity of malignant cells

a)      Acute immature cells

b)      Chronic differentiated cells

Predisposing Factors

Cause is unknown but several factors are associated with this disease e.g

1. Exposure to radiation
2. Chemical agents (Benzene)
3. Infectious  agent – Viruses
4. Genetic abnormalities – e.g in patients with down syndromes
5. Chemotherapy treatment e.g with alkylating agents
6. Myelofibrosis (fibrosis of bone marrow)
7. Heredity

Prevention  

Prevent the above factors

Acute Leukemia

1. It is a rapid disease involving primitive cells or blasts
2. It may be lymphoblastic (lymphatic) myeloblastic (myeloid) or menoblastic (very rare)

Assessment

Signs and symptoms (clinical feature)

1. Produced by proliferation and infiltration of bone marrow and other organs by immature WBC on the lymphocytic granulocytic or monocytic group
2. General malaise, tires easily, pallor form anaemia caused by depressed erythroporesis, haemorrhage and haemolysis
3. Persistent fever, due to neutropenia and granulocytes which encourages infection
4. Enlarged lymph nodes, splenomegally, abdominal discomfort from local tissue invasions
5. Bone pain, due to excess of uric acid in blood
6. Bleeding gum, epistaxis, petechiae, prolonged bleeding due to thrombocytopenia
7. Tachycardia, weight loss, dyspnoea on exertion intolerance to heat from increased metabolism by the tumour producing more heat.
8. Leukemia infiltration of the skin, tendency for leukemic tissue to infiltrate other organs and tissue.
9. Cerebral haemorrhages, cranial nerve paralysis, increased intracranial pressure leukemia cells invade the C.N.S  usual in patients in long remission
10. Pain from infarction Particularly The Spleen

Diagnostic Evaluation

1. Examination of blood – peripheral W.B.C count varies. there is decreased neutrophil and granulocytes, due to proliferation of abdominal leucocytes
2. Bone marrow biopsy – shows immature leucocytes called blasts
3. Lymphnode biopsy
4. Chest X-ray to detect mediastinal node and lung involvement.
5. Skeletal X-ray to detect skeletal lesions

Patient’s Problems/Nursing Diagnosis

1. Fatigue, nauseas, constipation and discomfort related to chemotherapy
2. Ineffective individual coping related to toxicity of drug
3. Infection related to granulocytopenia and mucosal damage
4. Bleeding tendencies
5. Pain related to proliferation of leukemia cells and enlarged abdominal organs
6. Fear related to the prognosis of the disease

Planning And Implementation

Treatment

Objective

a)      Restore normal bone marrow as quick as possible

b)      Achieve complete remission

c)      Provide the patient with long and normal life as long as possible

Chemotherapy

1.      Drugs are classified according to their effects on the cell chemistry

2.      Objective of chemotherapy is to induce remission (disappearance of abnormal cells in the bone marrow and peripheral blood)

3.      Initial treatment should be given in special leukemia units with a team approach to give best treatment

Underlying Principles Of Chemotherapy

1. Chemotherapy inhibits growth of leukemia cells by destroying or in activating nucleic acid or by interfering with their synthesis causes bone marrow depression and depresses the patients immunological deference mechanisms
2. drugs are given in combination (to exert different biological effects) at high level dose to produce greater leukemia cell damage
3. The treatment regimen is designed to affect cells in different phases of mitotic cycle
4. Usually there is intensive treatment with multiple agent at the beginning of the therapy to induce a remission followed by long term maintenance therapy
5. In acute leukemia assess the patient often for toxic side effects of drugs

Some Drugs Used In Acute Leukemia

1. Anti-metabolites complete with the natural metabolite, thus blocking the path way of synthesis of D.N.A or another cellular constituent (therapy blocking all growth) methotrexate antipurines (mercaptopurine) cystosine, arabinoside (Ara-C)
2. Alkylating agent may  exert their ant cancer effect by direct chemical interaction with the D.N.A of all cyclophosphamice
3. antibiotics – Inhibit synthesis of cell protein (adriamycin)
4. Plant alkaloids – Vincristine preventis cells division
5. Hormones – Suppress the growth of lymphocytes (adrenal corticosteroids – predinisone)
6. Other drugs – Lasparagine on amino-acids required by leukemia cells for cell growth.

Other Treatments Available

1. Bone marrow transplantation

a)      High dose chemotherapy and total body irradiation given first to destroy all leukemia cells

b)      Patient is then given I.V infusion of allogenic bone marrow

c)      Provide good supportive nursing care during the weeks following bone marrow transplantation, since he is unable to make W.B.C or platelets

d)     He is transfusion dependent and prone to infections

2. Cranial irradiation followed by intrathecal methotrixate to destroy meningo foci of leukemia cells mostly used in lymphocytic leukeamia
3. Granulocyte transfusion to teat sever neutropenia may be given daily with antibiotics granulocytes are obtained by cell separation techniques

Nursing Interventions (All Leukemia’s) Constant Observation Of A Patient Receiving Chemotherapy

1.      Obtain baseline data before chemotherapy is started

a)      Know the patients normal vital signs

b)      Follow up W.B.C count, differential count, HB and platelets  to be aware with drug effects

c)      Follow up blood electrolytes urea, creatinine, liver enzymes, billirubin

d)     Weight the patient 1 – 2 times weekly

e)      Assist with bone marrow aspiration P.R.N

2.      Watch for toxic signs during therapy

i.        Modification of patients chemotherapy regimen are based in laboratory and physical examination before each course of treatment

ii.      Monitor I.V drug as they may cause irritation and burning sensation on the vein especially nethotrexate and prednisone

i)                    Infuse slowly

ii)                  Change position of limb to prevent muscle cramps

iii)                Nausea, vomiting and burning sensation of the G.I.T may occur after drug infusion

iii.    Watch for mouth ulcers offer medicated mouth rinse

iv.    Alopecia is common in patient on vincristine offer wigs hair pieces, scarf’s etc the hair wall grow again.

v.      Observe for foot drop, weak hand grasp, ptosis of eyelids, vincristine may cause neuropathy

vi.    Assess for constipation and abdominal pain, vincristine may cause paralytic ileus

vii.  Watch for personality changes, retention of fluids, hypertension, gastric ulcers and diabetes mellitus – occur with prednisone therapy

viii.Watch for other drug effects changes effects e.g diarrhoea, stomatitis, maculopapular rash, phlebitis, bone marrow depression cardiac toxicity

ix.    E.C.G reading may be ordered

Supportive Measures for Patient with Leukemia or Lymphomia (All Leukemia)

Failure to improve is usually due to haemorrhage an infection

OBJECTIVE

Control complications so that chemo-therapeutic agents can show their effectiveness

1.      Eliminate morbidity and mortality resulting from haemorrhage

a)      Transfuse the patient with platelets, repeat 2 – 3 times per week, every platelet half life is 3 – 5 days

2.      Prevent and treat infections

a)      Monitor granulocytes

b)      Recognize infection promptly e.g monitor temperature, do cultures of blood, urine sputum and spinal fluid

c)      Chest X-rays

d)     Broad spectrum antibiotics prior culture is ready

e)      Watch for fungal infection indwelling catheter, antibiotics immunosuppression by drugs etc

3.      To prevent infections complication by control of environmental contamination

a)      Limits exogenous micro-organisms to the patient by nursing in special unit with unidirectional air flow “Barrier”

b)      If no special units use all measures to reduce environmental contamination (protective isolation)

Other Measures (All Leukemia’s)

1. Assist the patient to accept and participate in his therapeutics regimen

a)      Give expert care and support to encourage patient to endure the discomfort

b)      Help patient to adopt to incurable illness

i.        Patient may react with shock and anger, on knowing he has the disease

ii.      Deal with the anger in order to crate a therapeutic nurse/patient relationship

iii.    Allow patient and family to express their feelings

2. a) Control pain and discomfort e.g by milder analgesics and later stronger

      b) Antiemetics prior meals and sedatives

3.  Maintenance of fluids  3 – 4 litres daily to prevent uric acid, crystal in urine
4. Control fever by increased fluid intake and antipyretics
5. Frequent and special mouth care to remove dried blood to combat odour and sooth oral ulceration

·         Frequently mouth  washes

·         Soft tooth brush

·         Clean and lubricate mistrial and mouth

·         Soft diet

6. Nutrition

a)      Consider amino acids and vitamin

b)      If no response to planned diet then parenteral feed is needed

c)      There are taste changes so offer tempting foods

7. Continue with the welfare of the patient

Patients Education (All Leukemia)

1. Avoid sources of infection e.g crowds, unnecessary hospital visits, hands washing report signs of infection, report exposure to vericella, meals, hepatitis etc.
2. Adequate nutrition
3. assist in central venous catheter as appropriate
4. Monitor body weight
5. Visit t he dentists for oral infections
6. Avoid rectal mucosa trauma by preventing constipations
7. shower/bath daily playing attention axilla, skin, fold, perineum groin use shower
8. Use deodorants as antiperspirants block sweats glands and cause infection
9. Oral hygiene after meals
10. Watch for signs of bleeding
11. Use birth control pills as directed to prevent break through bleeding
12. Remember that leukemia is a treatable disease and most side effects of antileukemia drugs are short term.

evaluation

expected outcome

1. patient copes with chemotherapy and reports for treatment
2. Patient is free form infection
3. Shows no evidence of bleeding and manage bleeding when it occur
4. Have no pain or discomfort
5. Copes with the disease and related disorders e.g alopecia, catheter etc

Chronic Lymphocytic Leukemia

1. It is characterized by great increase in mature lymphocytes in the blood and in the lymphoid organs of the body
2. W.B.C may be excess of 100 x 109 per litre of blood and lymphocytes may be 90 – 99% of these W.B.C

Clinical Feature

1. Insidious onset in people over 60years
2. The disease may be asymptomatic for a number of years
3. Signs and symptoms are related to infiltration of lymph nodes, bone marrow, liver and spleen with lymphocytes

a)      Enlarged lymph nodes – cervical, axilla groin and splenomegally (may be painful)

b)      Anaemia and thrombocytopenia

c)      Weight loss, fever prone to infection

4. abnormalities of erythrocytes, granulocytes and platelets are common

TREATMENT

Objective

To achieve a remission of symptoms

Asymptomatic Patient with Chronic Lymphocytic Leukemia

a)      May not require treatment for years

b)      Support him with good nutrition, rest exercises, recreation and mental acivity

Symptomatic Patients

Patients with massive adenopathy, severe anaemia, thrombocytopenia, skin involvement and rearing infections

1. Chemotherapy

Relief the above signs and symptoms 

a)      Chlorambucil

b)      Combination of 3 – 4 drugs may be given to those who don’t respond to one drug

2. For anaemia

      From blood loss, form replacement of bone marrow by leukemia cells

a)      Radiotherapy for local disease

b)      Prednisone

c)      Chemotherapy

d)     Transfusion with whole blood or packed cell when haemolysis or bone marrow failure exists

3. For adenopathy

      Deep X-ray for localize nodes muscles or splenomegally

4. For haemorrhage

      Transfuse with blood

Planning and Implementation Nursing Management

Chronic Granulocytic Leukemia

1. Chronic granulocytic leukemia also known as myelocytic or myelogenous leukemia
2. It is characterized by an increased in all phases of white blood cells development
3. It affects the granulocytes produced by myeloid or bone marrow
4. There is often splenomegally and hepatomegally
5. It may also occur in acute form
6. Age 35-50 years and 60 – 70 years
7. It has a slow on set
8. It runs a progressive course over several years
9. The Philadelphia chromosome is present in the bone marrow in over 90% of these patients

Clinical Feature

1. Pallor’s, palpitations, dyspnoea from anaemia
2. Dragging sensation or enlargement of life sickle of abdomen (from splenomegally)
3. Elevated platelets count, elevated granulocytes at all stage of maturation
4. Weakness, loss of weight, anorexia
5. Tenderness and pain in long bone e.g Tibia ribs and sternum due to invasion by abnormal marrow.
6. Thrombocytosis shown by thromboembolic or haemorrhagic phenomena

TREATMENT

Objectives

To achieve remission of symptoms

1. Chemotherapy - Busalphan will induce complete or partial remission in majority of patient

a)      Following initial treatment put patient in a low long term doses for maintenance and high dose when the disease reccur

b)      Eventually the patient will not respond the acute exacerbation phase is called myeloblastic or blast crisis

c)      Treat the patient as in acute leukemia (See behind)

2. Bone marrow transfusion in the chronic stage
3. Leukophoresis (remove W.B.C from whole blood R.B.C transfused back to the patient)  may be done for a patient who need reduction of W.B.C quickly

·         See nursing support for patient receiving chemotherapy and other management measures behind

Complications of Leukemia

1. Cerebral haemorrhage
2. Acute gastrointestinal ulceration
3. Spelenomegally
4. Thrombocytopenic purpura
5. Side effects of drugs and other methods of treatment
6. Tumour of lymphatic tissue in many parts of the body e.g skin, breasts, tonsils and chest
7. Emaciation, oedema and ascites
8. Hepatomegally
9. Deafness
10. Impaired vision
11. Pain in the bones
12. Enlargement of parotid submandibular and sublingual salivary glands and the lecrimal glands
13. Joints effusions
14. Pericarditis, endocarditis, pleurisy and bronchopneumonia
15. leukemia meningitis