Leukemias

Nursing

1. LEUKEMIAS PRESENTED BY : Abhishek Yadav M Sc Nursing 1 st Year.

2. SPECIFIC OBJECTIVES Introduction of Leukemia. Definition of Leukemia. Incidence of Leukemia. Etiology & Risk factors of Leukemia. Pathophysiology of Leukemia. Types of Leukemia. Clinical manifestations of Leukemia. Diagnostic evaluation of Leukemia. Management of Leukemia.

3. INTRODUCTION Cancers of hematopoietic system are disorders that result from proliferation of malignant cells. Malignant cells are originated in bone marrow, Thymus, and lymphatic tissue. Blood cells that originate in bone marrow are called hematopoietic cells. Blood cells that originate in lymph are called lymphoid cells. Leukemia (Cancer of Bone marrow) Lymphoma (Cancer of lymphoid tissue)

4. DEFINITION Leukemia is a malignant disease of the blood- forming organs. Leukemia is a malignant progressive disease in which the bone marrow & other blood forming organs produce increased no. of immature / abnormal leucocytes, these suppresses the production of normal blood cells, leading to anemia & other symptoms.

5. INCIDENCE (in India) About 3- 4 per 100,000 population. These people account for 30% to 52% of all childhood cancers in males , and 19% to 52% in females.

6. ETIOLOGY AND RISK FACTORS The exact cause is unknown. Several factors are associated with leukemia include: Genetic factors: A high incidence of acute leukemias & chronic lymphocytic leukemias is reported in certain families.

7. Hereditary abnormalities associated with an increased incidence of leukemia are Down’s syndrome, Fanconi’s aplastic anemia, Trisomy -13 ( Patau’s syndrome), etc. Identical twins, fraternal twins, and siblings of children with leukemia are also at increased risk.

8. 2. Over-exposure to ionizing radiations and chemicals: Can become a major risk factor for development of leukemia, with disease developing years after initial exposure. Alkylating agents used to treat other cancers, especially in combination with radiation therapy, increase a person’s risk of leukemia. Workers exposed to chemical agents, such as benzene (an aromatic hydrocarbon), are at a much higher risk.

9. 3. Congenital abnormalities: Down’s syndrome.

10. The presence of : Primary immunodeficiency ,& Infection with the Human T-cell Leukemia Virus Type-1 ( HTLV -1).

11. PATHOPHYSIOLOGY

12. PATHOPHYSIOLOGY Due to etiological / risk factors Uncontrolled proliferation of WBC’s Normal bone marrow is replaced by immature & undifferentiated WBC’s / blast cells Then abnormal / immature WBC’s circulate in blood and infiltrate the blood forming organs (liver, spleen, lymph nodes) Organ infiltration symptoms are shown which include hepatomegaly , spleenomegaly , renal insufficiency, hyperuricemia , arthalgia , and increased ICP ( meningial infiltration)

13. TYPES There are 4 major types on the basis of acute versus chronic, the term acute and chronic refers to cell maturity and nature of disease onset: Acute lymphocytic leukemia. Acute myelogenous leukemia. Chronic lymphocytic leukemia. Chronic myelogenous leukemia.

14. Primary diff. b/w the four types is the rate of progression and where the cancer develops. Chronic leukemia cells do not mature all the way, so they are not as capable of defending against infections as normal lymphocytes. Acute leukemia cells begin to replicate before any immune functions have developed.

15. 1. Acute lymphocytic leukemia: Most common type of leukemia in children, and accounts for 15% in adults. In this type , immature lymphocytes proliferate in bone marrow : most are of B- cell origin. Age of onset : Before 14 year of age , peak incidence in b/w 2-9 years of age, and in older adults

16. Clinical manifestations : Fever, pale skin, bleeding, anorexia, fatigue and weakness. Bone , joint and abdominal pain. Generalized lymph- adenopathy , infection, weight loss. Hepatomegaly , spleenomegaly , headache, mouthsores . Increased ICP (nausea, vomitting , lethargy, cranial nerve dysfunction).

17. Diagnostic evaluation: Low RBC count, Hb , Hct , low platelet count. Low, or high WBC count. Transverse lines of rarefaction at ends of metaphysis of long bones on X-rays. Hyper cellular bone- marrow with lymphoblast. Lymphoblast also possible in CSF. Presence of Philadelphia chromosomes (20-25% cases).

18. 2. ACUTE MYELOGENOUS LEUKEMIA: This type represents only 1/4 th of all leukemias , in which 85% of this type in adults. It is characterized by uncontrolled proliferation of myeloblasts , precursors of granulocytes. There is hyperplasia of bone marrow.

19. Age of onset: Its onset is often abrupt & dramatic, a patient may have serious infections and abnormal bleeding from the onset of disease. Increase in incidence with advancing age, peak incidence b/w 60 and 70 year of age.

20. Clinical manifestations: Fatigue, weakness, headache, mouth sores, anemia, bleeding, fever, infection, sternal tenderness, gingival hyperplasia, minimal hepato-spleenomegaly & lymphadenopathy .

21. Diagnostic evaluation: low RBC count, Hb , Hct , Low platlet count, low to high WBC count with myeloblasts . high LDH , greatly hypercellular bone marrow with myeloblasts .

22. 3. CHRONIC LYMPHOCYTIC LEUKEMIA: It is most common type in adults. It is characterized by production and accumulation of functionally inactive but long-lived, small, mature- appearing lymphocytes. The type of lymphocytes involved is usually B-cell. The lymphocytes infiltrate the organ.

23. Lymphadenopathy is present throughout the body , and there is an increased incidence of infection because of T-cell deficiencies or hypogammaglobulinemia . Pressure on nerves from enlarged lymph nodes cause pain and even paralysis.

24. Onset: 50- 70 years of age, rare below 30 year of age.

25. Clinical mafestation : No symptoms frequently. Disease is often detected during examination for unrelated conditions, chronic fatigue, anorexia. Spleenomegaly & lymphadenopathy . Hepatomegaly , may progress to fever, night sweats, weight loss.

26. Diagnostic evaluation: Mild anemia and thrombocytopenia with disease progression; total WBC count >100,000 /micro L. Hemolytic anemia (4-11%). Thrombocytopenia purpura (2-4%). Hypogammaglobulinemia .

27. 4.CHRONIC MYELOGENOUS LEUKEMIA: It is caused by excessive development of mature neoplastic granulocytes in the bone marrrow . The excess neoplastic granulocytes move into peripheral blood in massive no. and ultimately infiltrate the liver & spleen. These cells contain a distinctive cytogenetic abnormality, the Philadelphia chromosomes, which serves as a disease marker and results from translocation of genetic material between chromosomes 9 and 22.

28. Age of onset: 25 to 60 year of age, peak incidence around 45 year of age.

29. Clinical manifestations: No symptoms are seen earlier. Fatigue and weakness, fever, sternal tenderness, weight loss, joint pain , pain in bone, massive spleenomegaly , increase in sweating.

30. Diagnostic findings: Low RBC’s count, Hb , Hct . High platlet count early, lower count later. Presence of Philadelphia chromosomes in 90% 0f patients.

31. CLINICAL MANIFESTATION Clinical features of leukemia relate to the problems caused by bone marrow failure and formation of leukemic infiltrates. As leukemia progresses : Fewer normal blood cells are produced. Abnormal WBC’s continue to accumulate ( don’t go through apoptosis).

32. The leukemic cells infiltrate the patient’s organs, leading to problems such as spleenomegaly , hepatomegaly , lymphadenopathy , bone pain, meningeal irritation and oral lesions. Solid masses resulting from collection of leukemic cells called chlormas can also occur.

33. DIAGNOSTIC EVALUATION A history collection. Physical examination. Peripheral blood evaluation ( WBC & platlet count). Bone marrow examination (sampling from hip bone). Lumbar puncture and CT scan are done to determine the presence of leukemic cells outside of blood & bone marrow.

34. MANAGEMENT PHARMACOLOGICAL MANAGEMENT : It includes the chemotherapy , which is a major form of treatment for leukemia. This drug treatment uses chemicals to kill leukemia cells. This can be a drug or a combination of drugs. these can be in form of pill or IV injection.

35. 1. For acute myelogenous leukemia : Anti-tumor antibiotics ( anthracyclins ): Daunorubicin , Doxorubicin, Idarubicin , Mitoxantrone .

36. Podophyllotoxin : Etoposide . Retinoid: Tretinoin . Anti-metabolites: Cytarabine, 6- thioguanine .

37. Miscellaneous: Arsenic tri-oxide. Combination of cytarabine and anti-tumor antibiotic.

38. For acute lymphocytic leukemia: Alkylating agents: Cyclophosphamide . Anti-tumor antibiotics ( anthracycline ): Daunorubicin , Doxorubicin.

39. Anti-metabolites: Cytarabine, 6- mercaptopurine , methotrexate Corticosteroids: Prednisolone , Dexamethasone .

40. Mitotic inhibitors / Vinca alkaloids: Vincristine . Biologic / targeted therapy: Dasatinib . Miscellaneous: L- asparaginase . Pregaspargase .

41. Other therapies: Cranial radiation, Intrathecal methotrexate or cytarbine

42. 3. Chronic myelogenous leukemia: Biologic / targeted therapy: Imatinib , Dasatinib . Miscellaneous: Hydroxyurea .

43. Combination chemotherapy including any of : Cytarabine, thioguanine , Daunorubicin , Methotrexate , Prednisone, Vincristine , L- asparaginase , Carmustine , 6- mercaptopurine .

44. Other therapies: Radiation (total body / spleen).

45. 4. Chronic lymphocytic leukemia: Alkylating agents : Chlorambucil , Cyclophosphamide . Antimetabolites : Fludarabine . Corticosteroid: Prednisone.

46. Biologic / targeted therapy: Alemtuzumab , Rituximab . Miscellaneous: Pentostatin . Other therapies: Radiation (total body, lymph nodes, or spleen)

47. SURGICAL MANAGEMENT : For acute myelogenous leukemia: Autologous or allogeneic hematopoietic stem cell transplant. 2. For acute lymphocytic leukemia: Allogeneic hematopoietic stem cell transplant.

48. 3. For chronic myelogenous leukemia: Hematopoietic cell transplant, alpha-interferon, leukapheresis . 4. For chronic lymphocytic leukemia: Spleenoctomy , allogeneic hematopoietic stem cell transplant.

49. NURSING MANAGEMENT : Asessment : Nursing diagnosis: 1. Ineffective protection / risk for infection related to neutropenia or leukocytosis secondary to leukemia or treatment. Intrvention : Assessing client. handwashing techniques. Client isolation.

50. Low bacteria diet (excluding fruits & vegetables). Daily bath with antibacterial soap. Maintain oral hygiene. Daily stool softeners (to reduce anal fissures). Perineal cleansing for every bowel movement. Avoid rectal suppositories & rectal thermometer. Temperature should be taken (oral, axilla , tympanic) every 4 hourly, report if more than 100.5 F or lower than 97.5 F ( because fever is only the symptom in neutropenic client).

51. 2. Decreased cardiac output related to thrombocytopenia secondary to either leukemia or treatment. Intervention: Institute bleeding precautions: Provide a soft toothbrush for oral hygiene Avoid commercial mouthwash containing alcohol. Avoid blowing or picking nose, straining at bowel movements, douching or using tampons, using razors during neutropenic phase.

52. Don’t administer IM/SC inj. Do not insert rectal suppository. Avoid aspirin containing drugs. Avoid urinary catheterization, if needed then only lesser sized. Avoid mucosal trauma during suctioning. Remove all sharp objects around client. Use pressure reducing mattress, proper change the position. Use only paper tape ,avoid strong adhesive (can cause skin adhesions).

53. 3. Fatigue related to side effects of treatments, low haemoglobin levels, pain, lack of sleep. Intervention: Assess for anemia. Assess for physical, mental and treatment related causes of fatigue. Encourage exercise to maintain strength. Allow for rest.

54. 4. imbalanced nutrition less than body requirements related to anorexia, pain or fatigue. Intervention: Administer anti-emetics. (before meal/ drinking). Administer local IV anlagesics . Provide high Cho meals & oral supplements. Weigh daily. If client can not tolerate oral foods for an extended period, begin TPN , as ordered. Monitor intake.

55. 5. Disturbed body image resulting from alopecia, weight loss and fatigue. Intervention: Before treatment , inform client about the potential for hair loss over entire body. Encourage use of hats, etc as desired. Explain the temporary nature of allopecia . Encourage him to balance rest with exercise to maintain muscle tone without developing severe fatigue.

56. REFRENCES Joyce M Black, Jane Hokanson Howks , A textbook of Medical Surgical Nursing Clinical Management for the Positive outcomes, * th Edition, Philadelphia: Sounders Elsevier 2009, Page no. -2115-24. Chintamani Lewis, Heit Kemper, Divksen , O’Brein , Bucher, A Textbook of Medical Surgical Nursing Assessment and Management of Clinical problems, New Dehli , Elseier , 2011, Page no.- 722-28. https://www.myoclinic.org/diseases-conditions/leukemia/basics https:// www.nursingcrib.com / pathophysiology -of-leukemia/