LEUKEMIAS NURSING MANAGEMENT

The term leukemia describes a malignant disorder of the blood and lymph-forming tissues of the body. The blood’s 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 4–6 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

May report: Shortness of breath with minimal exertion

May exhibit: Dyspnea, tachypnea

Cough

Crackles, rhonchi

Decreased breath sounds

Safety

May report: History of recent/recurrent infections, falls

Visual disturbances/impairment

Nosebleeds or other hemorrhages, spontaneous uncontrollable bleeding with minimal trauma

May exhibit: Fever, infections

Bruises, purpura, retinal hemorrhages, gum bleeding, or epistaxis

Enlarged lymph nodes, spleen, or liver (due to tissue invasion)

Papilledema and exophthalmos

Leukemic infiltrates in the dermis

Sexuality

May report: Changes in libido

Changes in menstrual flow, menorrhagia

Impotence

Teaching/Learning

May report: History of exposure to chemicals; e.g., benzene (commercially used toxic liquid that is also present in lead-free gasoline), excessive levels of ionizing radiation, previous treatment with chemotherapy, especially alkalizing agents

Chromosomal disorder; e.g., Down syndrome or Fanconi’s aplastic anemia

Exposure to virus; e.g., human T-cell leukemia/lymphoma virus-I (HTLV-I)

Discharge plan

considerations: May need assistance with therapy and treatment needs/supplies, shopping, food preparation, self-care activities, homemaker/maintenance tasks, transportation

Refer to section at end of plan for postdischarge considerations.

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.

4. Dealing with disease realistically.

5. Disease process/prognosis and therapeutic regimen understood.

6. Plan in place to meet needs after discharge.

Refer to CP: Cancer, for further discussion/expansion of interventions related to cancer care and for client teaching.

NURSING DIAGNOSIS: risk for Infection

Risk factors may include

Inadequate secondary defenses: alterations in mature WBCs (low granulocyte and abnormal lymphocyte count), increased number of immature lymphocytes; immunosuppression, bone marrow suppression (effects of therapy/transplant)

Inadequate primary defenses (stasis of body fluids, traumatized tissue)

Invasive procedures

Malnutrition; chronic disease

Possibly evidenced by

[Not applicable; presence of signs and symptoms establishes an actual diagnosis.]

DESIRED OUTCOMES/EVALUATION CRITERIA—CLIENT WILL:

Knowledge: Infection Control (NOC)

Identify actions to prevent/reduce risk of infection.

Demonstrate techniques, lifestyle changes to promote safe environment, achieve timely healing.

ACTIONS/INTERVENTIONS Infection Protection (NIC) Independent Place in private room. Screen/limit visitors as indicated. Prohibit use of live plants/cut flowers. Restrict fresh fruits and vegetables or make sure they are washed or peeled. Require good hand-washing protocol for all personnel and visitors. Monitor temperature. Note correlation between temperature elevations and chemotherapy treatments. Observe for fever associated with tachycardia, hypotension, subtle mental changes. Prevent chilling. Force fluids, administer tepid sponge bath. Encourage frequent turning and deep breathing. Auscultate breath sounds, noting crackles, rhonchi; inspect secretions for changes in characteristics; e.g., increased sputum production or change in sputum color. Observe urine for signs of infection; e.g., cloudy, foul-smelling, or presence of urgency or burning with voids. Handle client gently. Keep linens dry/wrinkle free. Inspect skin for tender, erythematous areas; open wounds. Cleanse skin with antibacterial solutions. Inspect oral mucous membranes. Provide good oral hygiene. Use a soft toothbrush, sponge, or swabs for frequent mouth care. Promote good perianal hygiene. Examine perianal area at least daily during acute illness. Provide sitz baths, using Betadine or Hibiclens if indicated. Avoid rectal temperatures, use of suppositories. Coordinate procedures and tests to allow for uninterrupted rest periods. Encourage increased intake of foods high in protein and fluids with adequate fiber.

RATIONALE Protect client from potential sources of pathogens/infection. Note: Profound bone marrow suppression, neutropenia, and chemotherapy place client at great risk for infection. Prevents cross-contamination/reduces risk of infection. Although fever may accompany some forms of chemotherapy, progressive hyperthermia occurs in some types of infections, and fever (unrelated to drugs or blood products) occurs in most leukemia clients. Note: Septicemia may occur without fever. Helps reduce fever, which contributes to fluid imbalance, discomfort, and CNS complications. Prevents stasis of respiratory secretions, reducing risk of atelectasis/pneumonia. Early intervention is essential to prevent sepsis/septicemia in immunosuppressed person. Prevents sheet burn/skin excoriation. May indicate local infection. Note: Open wounds may not produce pus because of insufficient number of granulocytes. The oral cavity is an excellent medium for growth of organisms and is susceptible to ulceration and bleeding. Promotes cleanliness, reducing risk of perianal abscess; enhances circulation and healing. Note: Perianal abscess can contribute to septicemia and death in immunosupressed clients. Conserves energy for healing, cellular regeneration. Promotes healing and prevents dehydration. Note: Constipation potentiates retention of toxins and risk of rectal irritation/tissue injury.

Avoid/limit invasive procedures (e.g., venipuncture and injections) as possible. Collaborative Monitor laboratory studies, e.g.: CBC, noting whether WBC count falls or sudden changes occur in neutrophils; Gram’s stain cultures/sensitivity. Review serial chest x-rays. Prepare for/assist with leukemia-specific treatments such as chemotherapy, radiation, and/or bone marrow transplant. Administer medications as indicated, e.g.: antibiotics; Colony-stimulating factors (CSFs): e.g., sargramostim (Leukine), filgrastim (Neupogen), pegfilgrastim (Neulasta). Avoid use of aspirin-containing antipyretics. Provide nutritious diet, high in protein and calories, avoiding raw fruits, vegetables, or uncooked meats.

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 procedures and risk of infection. Note: Myelosuppression may be cumulative in nature, especially when multiple drug therapy (including steroids) is prescribed. Decreased numbers of normal/mature WBCs can result from the disease process or chemotherapy, compromising the immune response and increasing risk of infection. Verifies presence of infections; identifies specific organisms and appropriate therapy. Indicator of development/resolution of respiratory complications. Leukemia is usually treated with a combination of these agents, each requiring specific safety precautions for client and care providers. May be given prophylactically or to treat specific infection. Restores WBCs destroyed by chemotherapy and reduces risk of severe infection and death in certain types of leukemia. Aspirin can cause gastric bleeding and further decrease platelet count. Proper nutrition enhances immune system. Minimizes potential sources of bacterial contamination.

NURSING DIAGNOSIS: risk for deficient Fluid Volume

Risk factors may include

Excessive losses; e.g., vomiting, hemorrhage, diarrhea

Decreased fluid intake; e.g., nausea, anorexia

Increased fluid need; e.g., hypermetabolic state, fever, predisposition for kidney stone formation/tumor lysis syndrome

Possibly evidenced by

[Not applicable; presence of signs and symptoms establishes an actual diagnosis.]

DESIRED OUTCOMES/EVALUATION CRITERIA—CLIENT WILL:

Hydration (NOC)

Demonstrate adequate fluid volume, as evidenced by stable vital signs; palpable pulses; urine output, specific gravity, and pH within normal limits.

Risk Control (NOC)

Identify individual risk factors and appropriate interventions.

Initiate behaviors/lifestyle changes to prevent development of dehydration.

ACTIONS/INTERVENTIONS Fluid Management (NIC) Independent Monitor I&O. Calculate insensible losses and fluid balance. Note decreased urine output in presence of adequate intake. Measure urine specific gravity and pH. Weigh daily. Monitor BP and HR. Evaluate skin turgor, capillary refill, and general condition of mucous membranes. Note presence of nausea, fever. Encourage fluids of up to 3–4 L/day when oral intake is resumed.

RATIONALE Tumor lysis syndrome occurs when destroyed cancer cells release toxic levels of potassium, phosphorus, and uric acid. Elevated phosphorus and uric acid levels can cause crystal formation in the renal tubules, impairing filtration and leading to renal failure. Measure of adequacy of fluid replacement and kidney function. Continued intake greater than output may indicate renal insult/obstruction. Changes may reflect effects of hypovolemia (bleeding/dehydration). Indirect indicators of fluid status/hydration. Affects intake, fluid needs, and route of replacement. Promotes urine flow, prevents uric acid precipitation, and enhances clearance of antineoplastic drugs.

Bleeding Precautions (NIC) Inspect skin/mucous membranes for petechiae, ecchymotic areas; note bleeding gums, frank or occult blood in stools and urine, oozing from invasive line sites. Implement measures to prevent tissue injury/bleeding; e.g., gentle brushing of teeth or gums with soft toothbrush, cotton swab, or sponge-tipped applicator; using electric razor instead of sharp razors when shaving; avoiding forceful nose blowing and needlesticks when possible; using sustained pressure (sandbags or pressure dressings) on oozing puncture/IV sites. Limit oral care to mouth rinse if indicated (e.g., a mixture of 1/4 tsp baking soda and 1/8 tsp salt in 8 oz water; may use hydrogen peroxide in water or saline for bleeding or infected oral tissue). Avoid mouthwashes with alcohol. Provide soft diet. Fluid Management (NIC) Collaborative Administer IV fluids as indicated. Administer medications as indicated, e.g.: Antiemetics: 5-HT3 receptor antagonist drugs such as ondansetron (Zofran) or granisetron (Kytril); Allopurinol (Zyloprim); Potassium acetate or citrate, sodium bicarbonate; Antiemetics. Bleeding Precautions (NIC) Monitor laboratory studies; e.g., platelets, Hb/Hct, clotting. Administer RBCs, platelets, clotting factors. Maintain external central vascular access device (subclavian or tunneled catheter or implanted port). Administer medications, e.g.: Stool softeners; Oral contraceptives.

Suppression of bone marrow and platelet production places client at risk for spontaneous/uncontrolled bleeding. Fragile tissues and altered clotting mechanisms increase the risk of hemorrhage following even minor trauma. When bleeding is present, even gentle brushing may cause more tissue damage. Alcohol has a drying effect and may be painful to irritated tissues. May help reduce gum irritation. Maintains fluid/electrolyte balance in the absence of oral intake; prevents or minimizes tumor lysis syndrome, reduces risk of renal complications. Relieves nausea/vomiting associated with administration of chemotherapy agents. Improves renal excretion of toxic byproducts from breakdown of leukemia cells. Reduces the chances of nephropathy as a result of uric acid production. May be used to alkalinize the urine, preventing or minimizing tumor lysis syndrome/kidney stones. Reducing nausea enhances oral intake. When the platelet count is less than 20,000/mm (because of proliferation of WBCs and/or bone marrow suppression secondary to antineoplastic drugs), client is prone to spontaneous life-threatening bleeding. Decreasing Hb/Hct is indicative of bleeding (may be occult). Restores/normalizes RBC count and oxygen-carrying capacity to correct anemia. Used to prevent/treat hemorrhage. Eliminate peripheral venipuncture as source of bleeding. Helpful in reducing straining at stool which can cause trauma to rectal tissues. Minimizes blood loss by stopping or slowing menstrual flow.

NURSING DIAGNOSIS: acute Pain

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 CRITERIA—CLIENT WILL:

Pain Level (NOC)

Report pain is relieved/controlled.

Appear relaxed and able to sleep/rest appropriately

ACTIONS/INTERVENTIONS

RATIONALE

Pain Management (NIC) Independent Investigate reports of pain. Note changes in degree (use scale of 0–10) and site. Monitor vital signs, note nonverbal cues; e.g., muscle tension, restlessness. Provide quiet environment and reduce stressful stimuli; e.g., noise, lighting, constant interruptions. Place in position of comfort and support joints, extremities with pillows/padding. Reposition periodically and provide/assist with gentle ROM exercises. Provide comfort measures (e.g., massage, cool packs) and psychologic support (e.g., encouragement, presence). Review/promote client’s own comfort interventions; e.g., position, physical activity/nonactivity. Evaluate and support client’s coping mechanisms. Encourage use of stress management    techniques; e.g., relaxation/deep-breathing exercises, guided imagery, visualization, therapeutic touch. Assist with/provide diversional activities, relaxation techniques. Collaborative Monitor uric acid level as appropriate. Administer medications as indicated: Analgesics; e.g., acetaminophen (Tylenol); Opioids; e.g., codeine, morphine, hydromorphone (Dilaudid); Antianxiety agents; e.g., diazepam (Valium), lorazepam (Ativan).

Helpful in assessing need for intervention; may indicate developing complications. May be useful in evaluating verbal comments and effectiveness of interventions. Promotes rest and enhances coping abilities. May decrease associated bone/joint discomfort. Improves tissue circulation and joint mobility. Minimizes need for/enhances effects of medication. 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. Using own learned perceptions/behaviors to manage pain can help client cope more effectively. Facilitates relaxation, augments pharmacologic therapy, and enhances coping abilities. Helps with pain management by redirecting attention. Rapid turnover and destruction of leukemic cells during chemotherapy can elevate uric acid, causing swollen painful joints in some clients. Note: Massive infiltration of WBCs into joints can also result in intense pain. Given for mild pain not relieved by comfort measures. Note: Avoid aspirin-containing products because they may potentiate hemorrhage. Use around-the-clock, rather than prn, when pain is severe. Note: Use of patient-controlled analgesia (PCA) is beneficial in preventing peaks and valleys associated with intermittent drug administration and increases client’s sense of control. May be given to enhance the action of analgesics/opioids.

NURSING DIAGNOSIS: Activity Intolerance

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

DESIRED OUTCOMES/EVALUATION CRITERIA—CLIENT WILL:Endurance (NOC)

Report a measurable increase in activity tolerance.

Participate in ADLs to level of ability.

Demonstrate a decrease in physiological signs of intolerance; e.g., pulse, respiration, and BP remain within client’s normal range.

ACTIONS/INTERVENTIONS Energy Management (NIC) Independent Evaluate reports of fatigue, noting inability to participate in activities or ADLs. Encourage client to keep a diary of daily routines and energy levels, noting activities that increase fatigue. Provide quiet environment and uninterrupted rest periods. Encourage rest periods before meals. Implement energy-saving techniques; e.g., sitting, rather than standing, use of shower chair. Assist with ambulation/other activities as indicated. Recommend small, nutritious, high-protein meals and snacks throughout the day. Schedule meals around chemotherapy. Give oral hygiene before meals. Collaborative Provide supplemental oxygen.

RATIONALE Effects of leukemia, anemia, and chemotherapy may be cumulative (especially during acute and active treatment phase), necessitating assistance. Helps client prioritize activities and arrange them around fatigue pattern. Restores energy needed for activity and cellular regeneration/tissue healing. Maximizes available energy for self-care tasks. Smaller meals require less energy for digestion than larger meals. Increased intake provides fuel for energy. (Refer to CP: Cancer, ND: imbalanced Nutrition: less than body requirements.) Maximizes oxygen available for cellular uptake, improving tolerance of activity.

 

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 CRITERIA—CLIENT 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/INTERVENTIONS Teaching: Disease Process (NIC) Independent Review pathology of specific form of leukemia and various treatment options.

RATIONALE Treatments can include various antineoplastic drugs, transfusions, peripheral progenitor (stem) cell transplant or bone marrow transplant.

 

POTENTIAL CONSIDERATIONS following acute hospitalization (dependent on client’s age, physical condition/presence of complications, personal resources, and life responsibilities)

risk for Infection—inadequate secondary defenses: alterations in mature WBCs (low granulocyte and abnormal lymphocyte count), increased number of immature lymphocytes, immunosuppression, bone marrow suppression (effects of therapy/ transplant).

ineffective Role Performance—situational crisis, health alterations, change in physical capacity.

ineffective Therapeutic Regimen Management—complexity of therapeutic regimen, decisional conflicts, economic difficulties, excessive demands made on individual or family, perceived benefits, powerlessness.

interrupted Family Processes—situational crisis (illness, disabling/expensive treatments).