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The term leukemia describes a malignant disorder of the blood and lymph-forming tissues of the body. The bloods
cellular components originate primarily in the marrow of bones such as the sternum, iliac crest, and cranium. All blood
cells begin as immature cells (blasts or stem cells) that differentiate and mature into RBCs, platelets, and various
types of WBCs. In leukemia, many immature or ineffective WBCs crowd out the developing normal cells. As the
normal cells are replaced by leukemic cells, anemia, neutropenia, and thrombocytopenia occur.
Leukemia is acute when WBCs proliferate so rapidly that they lose the ability to regulate cell division and do not
differentiate into mature cells. In the chronic forms of leukemia, the disease develops gradually. The type of leukemia
is based on the predominant cell line that is affected. In adults, the most common of the acute leukemias is acute
myelocytic leukemia, which affects any type of WBC other than lymphocytes. The most common of the chronic
leukemias is chronic lymphocytic leukemia, which is characterized by an abnormal increase in lymphocytes.
Current treatments include chemotherapy, biologic therapy (e.g., monoclonal antibodies or interferon), radiation
therapy, or transplantation (bone marrow transplant, peripheral stem cell transplant, or umbilical cord blood
transplant).
Care Setting
Acute inpatient care on medical or oncology unit for initial evaluation and treatment typically 46 weeks, and then at
the community level.
Related Concerns
Cancer
Psychosocial aspects of care
Transplantation: postoperative and lifelong needs
Client Assessment Database
Data depend on degree/duration of the disease and other organ involvement.
Activity/Rest
May report: Fatigue, malaise, weakness, inability to engage in usual activities, flu-like symptoms
May exhibit: Muscle wasting, anemia
Increased need for sleep, somnolence
Circulation
May report: Palpitations
May exhibit: Tachycardia, heart murmurs
Pallor of skin, mucous membranes
Cranial nerve deficits and/or signs of cerebral hemorrhage
Ego Integrity
May report: Feelings of helplessness/hopelessness
May exhibit: Depression, withdrawal, anxiety, fear, anger, irritability
Mood changes, confusion
Elimination
May report: Diarrhea, perianal tenderness, pain
Bright red blood on tissue paper, tarry stools
Blood in urine, decreased urine output
May exhibit: Perianal abscess; hematuria
Food/Fluid
May report: Loss of appetite, anorexia, vomiting
Change in taste/taste distortions
Weight loss
Pharyngitis, dysphagia
May exhibit: Abdominal distention, decreased bowel sounds
Splenomegaly, hepatomegaly, jaundice
Stomatitis, oral ulcerations
Gum hypertrophy (gum infiltration may be indicative of acute monocytic leukemia)
Neurosensory
May report: Lack of coordination/decreased coordination
Mood changes, confusion, disorientation, lack of concentration
Dizziness; numbness, tingling, paresthesias
May exhibit: Muscle irritability, seizure activity, uncoordinated movements
Pain/Discomfort
May report: Abdominal pain, headaches, bone/joint pain, sternal tenderness, muscle cramping
May exhibit: Guarding/distraction behaviors, restlessness; self-focus
Respiration
Diagnostic Studies
CBC: Usually indicates a normocytic, normochromic anemia.
Hemoglobin: May be less than 10 g/100 mL.
Reticulocytes: Count is usually low. Teardrop and nucleated red blood cells may be seen.
Platelet count: May vary from normal to very low (less than 50,000/mm).
WBC: May be more than 50,000/cm with increased immature WBCs (shift to left). Leukemic blast cells may be
present.
Prothrombin time (PT)/activated partial thromboplastin time (aPTT): May be prolonged. (Disseminated
intravascular coagulation [DIC] may occur with acute myelogenous leukemia, but it is especially common in acute
promyelocytic leukemia.)
LDH: May be elevated.
Serum/urine uric acid: May be elevated.
Bence Jones protein (urine): May be increased.
Bone marrow biopsy: Abnormal WBCs usually make up 50% or more of the WBCs in the bone marrow. Often 60%
90% of the cells are blast cells, with erythroid precursors, mature cells, and megakaryocytes reduced.
Chest radiograph and lymph node biopsies: May indicate degree of involvement.
Lumbar puncture: May find leukemic cells in cerebrospinal fluid (CSF)
Cytogenetics: Examination of chromosome abnormalities from samples of peripheral blood, bone marrow, or lymph
nodes that may indicate prognostic features.
Nursing Priorities
1. Prevent infection during acute phases of disease/treatment.
2. Maintain circulating blood volume.
3. Alleviate pain.
4. Promote optimal physical functioning.
5. Provide psychologic support.
6. Provide information about disease process/prognosis and treatment needs.
Discharge Goals
1. Complications prevented/minimized.
2. Pain relieved/controlled.
3. ADLs met by self or with assistance.
ACTIONS/INTERVENTI RATIONALE
ONS
1.
Protect client from potential
Infection Protection
sources of
(NIC)
pathogens/infection.Note: Profound
bone marrow suppression,
neutropenia, and chemotherapy
Independent
place client at great risk for
infection.
1.
Place in private
room. Screen/limit visitors 2.
Prevents crossas indicated. Prohibit use of contamination/reduces risk of
live plants/cut flowers.
infection.
Restrict fresh fruits and
3.
Although fever may
vegetables or make sure
accompany some forms of
they are washed or peeled. chemotherapy, progressive
2.
Require good hand- hyperthermia occurs in some types
washing protocol for all
of infections, and fever (unrelated to
personnel and visitors.
drugs or blood products) occurs in
most leukemia
3.
Monitor
clients. Note:Septicemia may occur
temperature. Note
without fever.
correlation between
temperature elevations and 4.
Helps reduce fever, which
chemotherapy treatments. contributes to fluid imbalance,
Observe for fever
discomfort, and CNS complications.
associated with
5.
Prevents stasis of respiratory
tachycardia, hypotension, secretions, reducing risk of
subtle mental changes.
atelectasis/pneumonia.
4.
Prevent chilling.
6.
Early intervention is
Force fluids, administer
essential to prevent
tepid sponge bath.
sepsis/septicemia in
5.
Encourage frequent immunosuppressed person.
turning and deep breathing. 7.
Prevents sheet burn/skin
6.
Auscultate breath excoriation.
sounds, noting crackles,
8.
May indicate local
rhonchi; inspect secretions infection.Note: Open wounds may
for changes in
not produce pus because of
characteristics; e.g.,
insufficient number of granulocytes.
increased sputum
9.
The oral cavity is an
production or change in
excellent medium for growth of
sputum color. Observe
organisms and is susceptible to
urine for signs of infection; ulceration and bleeding.
e.g., cloudy, foul-smelling,
Promotes cleanliness,
or presence of urgency or 10.
reducing
risk of perianal abscess;
burning with voids.
enhances circulation and
7.
Handle client
healing.Note: Perianal abscess can
gently. Keep linens
contribute to septicemia and death
dry/wrinkle free.
in immunosupressed clients.
8.
Inspect skin for
11.
Conserves energy for
tender, erythematous areas; healing, cellular regeneration.
open wounds. Cleanse skin
Promotes healing and
with antibacterial solutions. 12.
prevents
9.
Inspect oral mucous dehydration. Note: Constipation
membranes. Provide good potentiates retention of toxins and
oral hygiene. Use a soft
risk of rectal irritation/tissue injury.
toothbrush, sponge, or
swabs for frequent mouth
care.
10.
Promote good
perianal hygiene. Examine
1.
Break in skin could provide
an entry for pathogenic/potentially
lethal organisms. Use of central
venous lines (e.g., tunneled catheter
or implanted port) can effectively
reduce need for frequent invasive
Collaborative
procedures and risk of
1.
Monitor laboratory infection. Note:Myelosuppression
may be cumulative in nature,
studies, e.g.:
especially when multiple drug
2.
CBC, noting
whether WBC count falls therapy (including steroids) is
or sudden changes occur in prescribed.
neutrophils;
Decreased numbers of
3.
Grams stain
normal/mature WBCs can result
cultures/sensitivity.
from the disease process or
4.
Review serial chest chemotherapy, compromising the
x-rays.
immune response and increasing
5.
Prepare for/assist risk of infection.
with leukemia-specific
treatments such as
1.
Verifies presence of
chemotherapy, radiation, infections; identifies specific
and/or bone marrow
organisms and appropriate therapy.
transplant.
2.
Indicator of
6.
Administer
development/resolution of
medications as indicated, respiratory complications.
e.g.: antibiotics;
3.
Leukemia is usually treated
7.
Colony-stimulating with a combination of these agents,
factors (CSFs): e.g.,
each requiring specific safety
sargramostim (Leukine), precautions for client and care
filgrastim (Neupogen),
pegfilgrastim (Neulasta).
8.
Avoid use of
aspirin-containing
antipyretics.
9.
Provide nutritious
diet, high in protein and
calories, avoiding raw
fruits, vegetables, or
uncooked meats.
providers.
4.
May be given
prophylactically or to treat specific
infection.
5.
Restores WBCs destroyed
by chemotherapy and reduces risk
of severe infection and death in
certain types of leukemia.
6.
Aspirin can cause gastric
bleeding and further decrease
platelet count.
7.
Proper nutrition enhances
immune system. Minimizes
potential sources of bacterial
contamination.
ACTIONS/INTERVENTI RATIONALE
ONS
1.
Tumor lysis
syndrome occurs when
1.
Suppression of bone
marrow and platelet
Bleeding Precautions
production places client at
(NIC)
risk for
spontaneous/uncontrolled
1.
Inspect
skin/mucous membranes bleeding.
for petechiae, ecchymotic 2.
Fragile tissues and
areas; note bleeding gums, altered clotting mechanisms
frank or occult blood in
increase the risk of
stools and urine, oozing
hemorrhage following even
from invasive line sites.
minor trauma.
2.
Implement
3.
When bleeding is
measures to prevent tissue present, even gentle brushing
injury/bleeding; e.g., gentle may cause more tissue
brushing of teeth or gums damage. Alcohol has a drying
with soft toothbrush, cotton effect and may be painful to
swab, or sponge-tipped
irritated tissues.
May be related to
Physical agents; e.g., enlarged organs/lymph nodes, bone marrow packed with leukemic cells
Chemical agents; e.g., antileukemic treatments
Psychologic manifestations; e.g., anxiety, fear
Possibly evidenced by
Reports of pain (bone, nerve, headaches, and so forth)
Guarding/distraction behaviors, facial grimacing, alteration in muscle tone
Autonomic responses
DESIRED OUTCOMES/EVALUATION CRITERIACLIENT WILL:
Pain Level (NOC)
Report pain is relieved/controlled.
Appear relaxed and able to sleep/rest appropriately
ACTIONS/INTERVENTIO
NS
RATIONALE
1.
Helpful in
assessing need for
intervention; may indicate
Independent
1.
Investigate reports of
pain. Note changes in degree
(use scale of 010) and site.
2.
Monitor vital signs,
note nonverbal cues; e.g.,
muscle tension, restlessness.
3.
Provide quiet
environment and reduce
stressful stimuli; e.g., noise,
lighting, constant
interruptions.
4.
Place in position of
comfort and support joints,
extremities with
pillows/padding.
5.
Reposition
periodically and
provide/assist with gentle
ROM exercises.
6.
Provide comfort
measures (e.g., massage, cool
packs) and psychologic
support (e.g., encouragement,
presence).
7.
Review/promote
clients own comfort
interventions; e.g., position,
physical activity/nonactivity.
8.
Evaluate and support
clients coping mechanisms.
9.
Encourage use of
stress management
techniques; e.g.,
relaxation/deep-breathing
exercises, guided imagery,
visualization, therapeutic
touch.
1.
Assist with/provide
diversional activities,
developing complications.
2.
May be useful in
evaluating verbal
comments and
effectiveness of
interventions.
3.
Promotes rest and
enhances coping abilities.
4.
May decrease
associated bone/joint
discomfort.
5.
Improves tissue
circulation and joint
mobility.
6.
Minimizes need
for/enhances effects of
medication.
7.
Successful
management of pain
requires client
involvement. Use of
effective techniques
provides positive
reinforcement, promotes
sense of control, and
prepares client for
interventions to be used
after discharge.
8.
Using own learned
perceptions/behaviors to
manage pain can help
client cope more
effectively.
9.
Facilitates
relaxation, augments
pharmacologic therapy,
and enhances coping
abilities.
10.
Helps with pain
management by redirecting
attention.
11.
Rapid turnover and
destruction of leukemic
cells during chemotherapy
relaxation techniques.
Collaborative
1.
Monitor uric acid
level as appropriate.
2.
Administer
medications as indicated:
3.
Analgesics; e.g.,
acetaminophen (Tylenol);
4.
Opioids; e.g.,
codeine, morphine,
hydromorphone (Dilaudid);
5.
Antianxiety agents;
e.g., diazepam (Valium),
lorazepam (Ativan).
May be related to
Generalized weakness; reduced energy stores, increased metabolic rate from massive production of leukocytes
Imbalance between oxygen supply and demand (anemia/hypoxia)
Therapeutic restrictions (isolation/bedrest); effect of drug therapy
Possibly evidenced by
Verbal report of fatigue or weakness
Exertional discomfort or dyspnea
Abnormal HR or BP response
ACTIONS/INTERVENTION RATIONALE
S
1.
Effects of
Energy Management (NIC) leukemia, anemia, and
chemotherapy may be
cumulative (especially
Independent
during acute and active
treatment phase),
1.
Evaluate reports of
necessitating assistance.
fatigue, noting inability to
participate in activities or
2.
Helps client
ADLs.
prioritize activities and
2.
Encourage client to keep arrange them around
fatigue pattern.
a diary of daily routines and
energy levels, noting activities 3.
Restores energy
that increase fatigue.
needed for activity and
cellular
3.
Provide quiet
environment and uninterrupted regeneration/tissue
healing.
rest periods. Encourage rest
periods before meals.
4.
Maximizes
available energy for self4.
Implement energysaving techniques; e.g., sitting, care tasks.
rather than standing, use of
5.
Smaller meals
shower chair. Assist with
require less energy for
ambulation/other activities as digestion than larger
indicated.
meals. Increased intake
provides fuel for energy.
5.
Recommend small,
nutritious, high-protein meals (Refer to CP: Cancer,
and snacks throughout the day. ND: imbalanced
Nutrition: less than body
Schedule meals around
requirements.)
chemotherapy. Give oral
hygiene before meals.
1.
Maximizes
oxygen available for
Collaborative
cellular uptake,
improving tolerance of
1.
Provide supplemental activity.
oxygen.
NURSING DIAGNOSIS: deficient Knowledge [Learning Need] regarding disease, prognosis, treatment, self-care, and discharge
needs
May be related to
Lack of exposure to resources
Information misinterpretation/lack of recall
Possibly evidenced by
Verbalization of problem/request for information
Statement of misconception
DESIRED OUTCOMES/EVALUATION CRITERIACLIENT WILL:
Knowledge: Illness Care (NOC)
Verbalize understanding of condition/disease process and potential complications.
Verbalize understanding of therapeutic needs.
Initiate necessary lifestyle changes.
Participate in treatment regimen.
ACTIONS/INTERVENTION RATIONALE
S
1.
Treatments can
Teaching: Disease Process
include various
(NIC)
antineoplastic drugs,
transfusions, peripheral
progenitor (stem) cell
Independent
transplant or bone
marrow transplant.
1.
Review pathology of
specific form of leukemia and
various treatment options.