Nursing

1. LEUKEMIAS
PRESENTED BY:
Abhishek Yadav
M Sc Nursing 1st 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:
1. 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. 4. The presence of :
– Primary immunodeficiency ,&
– Infection with the Human T-cell Leukemia Virus
Type-1 (HTLV-1).

11. PATHOPHYSIOLOGY

12. 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:
1. Acute lymphocytic leukemia.
2. Acute myelogenous leukemia.
3. Chronic lymphocytic leukemia.
4. Chronic myelogenous leukemia.

13. 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.

14. 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

15. • 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).

16. • 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).

17. 2. ACUTE MYELOGENOUS LEUKEMIA:
This type represents only 1/4th 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.

18. • 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.

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

20. • 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.

21. 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.

22. 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.

23. • Onset:
– 50- 70 years of age, rare below 30 year of age.

24. • 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.

25. • 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.

26. 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.

27. • Age of onset:
– 25 to 60 year of age, peak incidence around 45
year of age.

28. • 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.

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

30. 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).

31. – 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.

32. 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.

33. 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.

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

35. Podophyllotoxin:
– Etoposide.
Retinoid:
– Tretinoin.
Anti-metabolites:
– Cytarabine,
– 6-thioguanine.

36. Miscellaneous:
– Arsenic tri-oxide.
Combination of cytarabine and anti-tumor
antibiotic.

37. 2. For acute lymphocytic leukemia:
 Alkylating agents:
– Cyclophosphamide.
 Anti-tumor antibiotics (anthracycline):
– Daunorubicin,
– Doxorubicin.

38.  Anti-metabolites:
– Cytarabine,
– 6-mercaptopurine,
– methotrexate
Corticosteroids:
– Prednisolone,
– Dexamethasone.

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

40. Other therapies:
– Cranial radiation,
– Intrathecal methotrexate or cytarbine

41. 3. Chronic myelogenous leukemia:
Biologic / targeted therapy:
– Imatinib,
– Dasatinib.
Miscellaneous:
– Hydroxyurea.

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

43. Other therapies:
– Radiation (total body / spleen).

44. 4. Chronic lymphocytic leukemia:
Alkylating agents :
– Chlorambucil,
– Cyclophosphamide.
Antimetabolites:
– Fludarabine.
Corticosteroid:
– Prednisone.

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

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

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

48. • 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.

49. • 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 0 F or lower than 97.50 F ( because fever is
only the symptom in neutropenic client).

50. 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.

51. – 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).

52. 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.

53. 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.

54. 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.

55. 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/

56. THANKYOU