Leukemias account for approximately 8% of all human cancers, and approximately half of these cases are classified as acute leukemia. Acute leukemia, a malignant disease of the bloodforming organs, results when white blood cell (WBC) precursors proliferate in the bone marrow and lymphatic tissues. The cells eventually spread to the peripheral blood and all body tissues. Leukemia is considered acute when it has a rapid onset and progression and when, if it is left untreated, it leads to 100% mortality within days or months.
There are two major forms of acute leukemia: lymphocytic leukemia and nonlymphocytic leukemia. Lymphocytic leukemia involves the lymphocytes (cells that are derived from the stem cells and circulate among the blood, lymph nodes, and lymphatic organs) and lymphoid organs; nonlymphocytic leukemia involves hematopoietic stem cells that differentiate into monocytes, granulocytes, red blood cells (RBCs), and platelets. Up to 90% of acute leukemias are a form of lymphocytic leukemia, acute lymphoblastic leukemia (ALL), which is characterized by the abnormal growth of lymphocyte precursors called lymphoblasts. Acute myelogenous leukemia (AML) (also known as acute nonlymphocytic leukemia, or ANLL) causes the rapid accumulation of megakaryocytes (precursors to platelets), monocytes, granulocytes, and RBCs. As the disease progresses, the patient may have central nervous system (CNS) dysfunction with seizures, decreased mental status, or coma and renal insufficiency. Death occurs when the abnormal cells encroach on vital tissues and cause complications and organ dysfunction.
Approximately 30,000 new cases of leukemia occur each year, 28,000 of them adult cases and 2500 in children. AML is the most common adult leukemia, and two out of three children who develop acute leukemia develop ALL. Approximately 22,000 adults and children die of all forms of leukemia each year. Patients with AML or ALL can be kept in long-term remission or cured in approximately 20% to 30% of adults. Five-year survival rates for children with ALL are close to 80% and for children with AML close to 40%.
The exact cause of acute leukemia is unknown, but there are several risk factors. Overexposure to radiation even years before the development of the disease, particularly if the exposure is prolonged, is a major risk factor. Other risk factors include exposure to certain chemicals (benzene), medications (alkylating agents used to treat other cancers in particular), and viruses. Other related factors in children include genetic abnormalities such as Down syndrome, albinism, and congenital immunodeficiency syndrome. People who have been treated with chemotherapeutic agents for other forms of cancer have an increased risk for developing AML. Such cases generally develop within 9 years of chemotherapy.
Nursing care plan assessment and physical examination
Question the patient (or the parents of the patient, as appropriate) about any exposure to radiation, chemicals, viruses, and medications, including chemotherapy for cancer. Determine the adult patient’s occupation, and pay particular attention to radiation exposure of healthcare workers, workers in a power plant, or those serving in the military. Often, the patient describes a sudden onset of high fever and signs of abnormal bleeding (increased bruising, bleeding after minor trauma, nosebleeds, bleeding gums, petechiae, and prolonged menses). Some patients report increased fatigue and malaise, weight loss, palpitations, night sweats, and chills. Parents of children with leukemia often report a series of recurrent pulmonary, urinary tract, and perirectal infections. Patients may also complain of abdominal or bone pain.
The patient appears acutely ill, short of breath, and pale. Children are often febrile. When you inspect the lips and mouth, you may note bleeding gums and ulcerated areas of the mouth and throat. On palpation, you may feel lymph node swelling and enlargement of the liver and spleen. When you auscultate the patient’s lungs, you may hear decreased breath sounds, shallow and rapid respirations, a rapid heart rate, and a systolic ejection murmur.
When the diagnosis of acute leukemia is made, patients, parents, and significant others are shocked and fearful. If the patient is a child, determine the patient’s stage of development and his or her relationship with parents, caregivers, or grandparents. If the patient is an adult, determine the patient’s job, childcare, and financial responsibilities. Assess the patient’s home situation to determine the possibility of home healthcare. Determine the support systems available to the patient, including emotional, religious, financial, and social support.
Nursing care plan primary nursing diagnosis: Risk for infection related to decreased primary and secondary responses.
Nursing care plan intervention and treatment plan
The treatment for acute leukemia occurs in four phases: induction, consolidation, continuation, and treatment of (CNS) leukemia. During the induction phase, the patient receives an intense course of chemotherapy that is meant to cause a complete remission of the disease. Complete remission occurs when the patient has less than 5% of the bone marrow cells as blast cells and the peripheral blood counts are normal. Once remission has been sustained for 1 month, the patient enters the consolidation phase, during which she or he receives a modified course of chemotherapy to eradicate any remaining disease. The continuation, or maintenance, phase may continue for more than a year, during which time the patient receives small doses of chemotherapy every 3 to 4 weeks. Treatment of CNS leukemia is an essential component of therapy that has replaced irradiation, which leads to significant CNS complications, with intensive intrathecal and systemic chemotherapy for most patients.
Some patients also need transfusions with blood component therapy to control infection and prevent bleeding and anemia. Bone marrow transplantation (BMT) is an option for some patients. Early BMTs were allogenic transplants using stem cells that had been harvested from bone marrow from siblings or matched from unrelated relatives. In autologous BMTs in the 1980s, physicians began using frozen cells harvested from the donor’s own marrow during remission. More recently, a newer form of transplant has occurred with peripheral blood stem cell transplant (SCT) or peripheral blood progenitor cell transplant. Multiple pheresis, or removal of cells from the blood, provides the stem cells from the patient for transplantation. SCT permits the use of doses of chemotherapy and radiation therapy high enough to destroy the patient’s bone marrow; after the treatment is completed SCT restores blood-producing bone marrow stem cells. Radiation treatment is sometimes used to treat leukemic cells in the brain, spinal cord, or testicles.
Focus on providing comfort and support, managing complications, and providing patient education. Determine how the patient is coping with the disease and where you can best provide support. For some patients, improving their comfort is the highest priority, either physically, such as with a bed bath or back rub, or emotionally, such as by listening to fears and concerns and providing interesting distractions. Teach the patient stress- and pain-reduction techniques. Provide mouth care to lessen the discomfort from oral lesions. Support the patient’s efforts to maintain grooming and a positive body image. If the patient is a child, provide age-appropriate diversions, and work with the parents or caregivers to keep the significant others present and involved in the child’s care.
Protect the patient from injury and infection. To limit the risk of bleeding, hold firm pressure on all puncture wounds for at least 10 minutes or until they stop oozing. Limit the use of intramuscular injections and intravenous catheter placement when the patient is pancytopenic. Avoid taking rectal temperatures, using rectal suppositories, or performing a rectal examination. If the patient does not respond to treatment, be honest about the patient’s prognosis. Determine from parents how much information they want to share with the child about a terminal disease. Work with the patient, significant others, and chaplain to help the patient plan for a terminal illness and achieve a compassionate death.
Nursing care plan discharge and home health care guidelines
Teach the patient and significant others about the course of the disease, the treatment options, and how to recognize complications. Explain that the patient or parents need to notify the physician if any of the following occur: fever, chills, cough, sore throat, increased bleeding or bruising, new onset of bone or abdominal pain. Discuss the patient’s home environment to limit the risk of exposure to infections. Encourage the patient to avoid close contact with family pets because dogs, cats, and birds carry infections. Animal licks, bites, and scratches are sources of infection. The patient should not clean birdcages, litter boxes, or fish tanks. Additional sources of bacteria in the home include water in humidifiers, standing water in flower vases, and water in fish tanks. Encourage the patient to have air filters in furnaces and air conditioners changed weekly. Explain that raw fruits, vegetables, and uncooked meat carry bacteria and should be avoided. If the patient becomes injured, encourage the patient or significant others to apply pressure, use ice, and report excessive bleeding. Teach the patient to avoid blowing or picking the nose or straining at bowel movements to limit the risk of bleeding.
Explain the proper administration and potential side effects of any medications. Teach the patient how to manage pain with the prescribed analgesics and other side effects specific to each chemotherapeutic agent. Explain that the chemotherapy may cause weight loss, even anorexia. Encourage the patient to eat a diet high in calories and protein and to drink at least 2000 mL of fluids per day. If the chemotherapy leads to anorexia, encourage the patient to eat frequent, small meals several times a day. Arrange for a dietary consultation if needed before discharge. If the patient has oral lesions, teach the patient to use a soft toothbrush or cloth and to avoid hot, spicy foods and commercial mouthwashes, which can irritate mouth ulcers. Encourage the patient to take frequent rest periods during the day and to space activities with rest.
Urge the patient to maintain a realistic but positive attitude. The return to an independent lifestyle is possible with the efforts of a competent healthcare team and the patient’s cooperation. Provide a list of referral agencies as appropriate, such as the American Cancer Society, hospice, and support groups.