Leukemia, a term encompassing various cancers of the blood, impacts the blood-forming tissues, including the lymphatic system, bone marrow, and spleen. While recognized as the most prevalent cancer in children, leukemia can affect individuals across all age demographics.
Similar to other cancers, leukemia arises from DNA mutations within cells. The excessive production of abnormal cells disrupts the balance of healthy blood cells, leading to oxygen deficiency, impaired blood clotting, and compromised infection-fighting capabilities.
The development of leukemia is often attributed to a combination of environmental and genetic predisposing factors. Additional risk factors encompass exposure to certain chemicals, pesticides, radiation, viral infections, and smoking.
Classifications of Leukemia
Leukemia is categorized based on the rate of disease progression and the origin of the leukemic cells, whether they stem from lymphoid or myeloid lineages.
Classification by Disease Progression Rate:
- Acute Leukemia: Characterized by rapid cell division and disease advancement, necessitating prompt and aggressive intervention. It is more frequently observed in children.
- Chronic Leukemia: Involves cells that, while mature in appearance, exhibit dysfunctional behavior. The disease progression is slow, sometimes allowing for a “watch and wait” management strategy. It is more commonly diagnosed in adults.
Classification by Affected Cell Type:
- Myelogenous (Myeloid) Leukemia: Originates in myeloid cells, which are precursors to red blood cells, most white blood cells (excluding lymphocytes), and platelets.
- Lymphocytic Leukemia: Arises from lymphoid cells, the precursors of white blood cells known as lymphocytes.
Common Types of Leukemia
The four most frequently diagnosed types of leukemia are:
1. Acute Lymphocytic Leukemia (ALL): Predominantly affecting children, ALL is marked by the rapid multiplication of immature lymphocytes in the bone marrow. Clinical manifestations include fever, pallor, anorexia, bleeding tendencies, fatigue, weakness, bone, joint, and abdominal pain, generalized lymphadenopathy, and unintentional weight loss.
2. Acute Myelogenous Leukemia (AML): The most common acute leukemia in adults, AML is characterized by the uncontrolled proliferation of myeloblasts and bone marrow hyperplasia. Patients may present with fatigue, weakness, mouth sores, headaches, bleeding episodes, fever, anemia, and gingival hyperplasia.
3. Chronic Lymphocytic Leukemia (CLL): Predominantly seen in older adults, CLL, the most common chronic leukemia, involves the production and accumulation of functionally inactive, mature-appearing lymphocytes. In the early stages, symptoms may be absent; however, as the disease progresses, patients may experience fatigue, weakness, sternal tenderness, fever, weight loss, and bone and joint discomfort.
4. Chronic Myelogenous Leukemia (CML): Predominantly affecting adults, CML often remains asymptomatic in its initial phases. Later, individuals may develop night sweats, recurrent infections, weight loss, fatigue, and fever.
Nursing Process in Leukemia Care
Leukemia is a progressive and potentially life-threatening condition if left unmanaged. Although a definitive cure may not always be attainable, achieving remission is a realistic goal for many patients. Nurses play a critical role in supporting individuals with leukemia, particularly those undergoing intensive treatments like chemotherapy, radiation therapy, and biologic therapies. Nursing care focuses on managing and preventing complications, providing comfort, delivering comprehensive patient and family education, and offering continuous emotional support.
Nursing Assessment for Leukemia
The initial phase of nursing care involves a thorough nursing assessment to gather physical, psychosocial, emotional, and diagnostic data. This section will detail subjective and objective data relevant to leukemia.
Review of Health History
1. Evaluate General Symptoms: Based on the type of leukemia, common symptoms to assess include:
- Fever and chills
- Persistent Fatigue and weakness
- Recurrent Infections
- Unexplained Weight Loss
- Swollen Lymph Nodes (lymphadenopathy)
- Easy Bruising or Bleeding (petechiae, ecchymosis)
- Night Sweats
- Shortness of Breath (dyspnea)
- Bone or Joint Pain
2. Identify Nonmodifiable Risk Factors: Certain factors can increase the likelihood of developing specific types of leukemia:
- Age: Increased incidence in children under 15 years and adults over 50 years.
- Gender: Males have a slightly higher predisposition to leukemia than females.
- Race/Ethnicity: Individuals of Caucasian/White ethnicity exhibit a higher risk of leukemia.
- Family History: While most leukemia cases are not familial, having a close relative (parent, sibling) with AML or CLL may elevate risk.
- Congenital Conditions: Genetic syndromes like Down syndrome and bone marrow disorders are associated with an increased risk of acute leukemias.
3. Assess Smoking History: Smoking is a recognized modifiable risk factor for AML. Obtain a detailed smoking history from the patient, including current and past habits.
4. Review Medical History: Prior exposure to radiation therapy or chemotherapy treatments can elevate leukemia risk. Document any history of such treatments.
5. Investigate Chemical Exposures: Identify potential exposures to carcinogenic chemicals like benzene and formaldehyde, commonly found in:
- Benzene-containing products:
- Plastics and synthetic resins
- Rubber products
- Dyes and pigments
- Insecticides and pesticides
- Certain Medications
- Detergents and cleaning agents
- Cigarette smoke
- Motor vehicle exhaust
- Formaldehyde-containing products:
- Building materials (particleboard, plywood)
- Glues, adhesives, and resins
- Paints and lacquers
- Cleaning and disinfection supplies
Physical Assessment
1. Monitor for Flu-like Symptoms: Leukemia can compromise the immune system, leading to frequent infections. Assess for persistent fever, lymphadenopathy, and fatigue, which may mimic flu-like illnesses.
2. Abdominal Assessment: Hepatomegaly (enlarged liver) and splenomegaly (enlarged spleen) can occur due to the accumulation of leukemic cells. Palpate the abdomen to assess liver and spleen size, noting any tenderness, firmness, or nodularity.
3. Evaluate Weight Changes: Monitor for unexplained weight loss, which can be a significant indicator of leukemia progression or treatment side effects.
4. Assess Bone and Joint Pain: Inquire about bone pain, commonly reported in areas such as the ribs, breastbone, hips, shoulders, and long bones of the arms and legs. Also assess for joint pain and swelling, which may develop as the disease progresses.
5. Assess for Anemia Symptoms: Dysfunction of red blood cell production can lead to anemia. Monitor for symptoms including:
- Shortness of breath, especially on exertion
- Easy fatigability and generalized weakness
- Pallor of the skin and mucous membranes
6. Monitor for Bleeding Manifestations: Thrombocytopenia, resulting from platelet dysfunction, can cause bleeding tendencies. Assess for:
- Easy bruising and petechiae (small, pinpoint hemorrhages)
- Frequent nosebleeds (epistaxis)
- Gum bleeding, especially after brushing teeth
- Blood in the urine (hematuria) or stool (melena, hematochezia)
Diagnostic Procedures
1. Blood Tests: Initial diagnostic evaluation involves several blood tests:
- Complete Blood Count (CBC): To evaluate red blood cell, white blood cell, and platelet counts, and differential white blood cell count.
- Comprehensive Metabolic Panel: To assess overall organ function and electrolyte balance.
- Liver and Kidney Function Tests: To evaluate hepatic and renal function.
- Coagulation Panel (PT, aPTT, Fibrinogen): To assess blood clotting ability.
2. Further Blood Tests: Additional blood tests may be required to detect leukemia cells:
- Peripheral Blood Smear: To microscopically examine blood cells for abnormalities and presence of blast cells.
- Flow Cytometry: To identify specific cell types and markers on leukemia cells, aiding in classification.
3. Bone Marrow Aspiration and Biopsy: The definitive diagnosis of leukemia is often confirmed through bone marrow aspiration and biopsy. This procedure involves extracting a sample of bone marrow fluid and tissue, typically from the posterior iliac crest (hip bone), for microscopic examination and further analysis.
4. Imaging Tests: Imaging studies are used to evaluate the extent of leukemia and its impact on other organs and systems:
- Chest X-ray: To assess for mediastinal lymphadenopathy or lung involvement.
- CT Scan: To evaluate lymph nodes, spleen, liver, and other organs for leukemic infiltration.
- MRI Scan: To assess bone marrow involvement and central nervous system infiltration.
- Lumbar Puncture (Spinal Tap): To obtain cerebrospinal fluid (CSF) for analysis to determine if leukemia has spread to the central nervous system (CNS).
Nursing Interventions for Leukemia
Nursing interventions are crucial for supporting patients throughout their leukemia journey.
1. Collaborate on Treatment Planning: Work closely with the oncology/hematology team to understand and implement the individualized treatment plan, which is determined by:
- Patient’s overall health status and comorbidities
- Type and subtype of leukemia
- Disease stage and presence of metastasis
2. Educate on Chemotherapy Phases: For Acute Lymphocytic Leukemia (ALL), chemotherapy typically involves three phases:
- Induction Therapy: Aims to eliminate leukemia cells from the blood and bone marrow, inducing remission. Blood counts should normalize, and bone marrow should be free of leukemia cells. For childhood ALL, remission is often achieved within a month in the majority of cases.
- Consolidation Therapy (Intensification): Designed to eradicate any residual leukemia cells and prevent relapse. Administered in cycles over several months (typically 4-6 months).
- Maintenance Therapy: To sustain remission and prevent recurrence, often using a combination of oral chemotherapy, immunosuppressants, and corticosteroids, lasting for approximately two years.
3. Implement Multimodal Treatment Plan: Leukemia treatment often involves a combination of modalities:
- Chemotherapy: Cornerstone of leukemia treatment, using cytotoxic drugs to kill leukemia cells.
- Targeted Therapy: Drugs designed to target specific vulnerabilities in leukemia cells, such as specific proteins or genetic mutations.
- Radiation Therapy: High-energy rays to destroy leukemia cells, often used for localized disease or before stem cell transplant.
- Immunotherapy (Biologic Therapy): Enhancing the body’s immune system to fight leukemia cells.
- Hematopoietic Stem Cell Transplant (Bone Marrow Transplant): Replacing damaged or cancerous bone marrow with healthy stem cells.
4. Manage Treatment Side Effects: Cancer treatments can affect both cancerous and healthy cells, leading to various side effects:
- Infection (Neutropenia)
- Bleeding and Bruising (Thrombocytopenia)
- Anemia
- Fatigue
- Lymphedema
- Hair Loss (Alopecia)
- Loss of Appetite (Anorexia)
- Nausea and Vomiting
- Cognitive Changes (Chemo Brain)
- Constipation or Diarrhea
- Oral Mucositis (Mouth Sores)
- Skin and Nail Changes
5. Radiation Skin Care: After radiation therapy, provide specific skin care instructions: Use moisturizers (after treatment sessions, not before), protect skin from temperature extremes, wear loose cotton clothing, avoid shaving the treated area (use electric razor if needed), cleanse gently with lukewarm water and fragrance-free soaps.
6. Immunotherapy to Boost Immune Response: Immunotherapy aims to strengthen the body’s natural defenses against leukemia cells.
7. CAR T-cell Therapy Consideration: Chimeric Antigen Receptor (CAR) T-cell therapy, a type of immunotherapy, modifies a patient’s T cells to target and destroy leukemia cells. It’s often considered for relapsed or refractory leukemia cases.
8. Targeted Therapy to Attack Cancer Cells: Targeted therapies are designed to interfere with specific molecules involved in leukemia cell growth and survival, minimizing damage to healthy cells. Examples include Tyrosine Kinase Inhibitors and Monoclonal Antibodies.
9. Hematopoietic Stem Cell Transplant Preparation: Prepare patients for potential stem cell transplant, which replaces damaged bone marrow with healthy stem cells to restore normal blood cell production and potentially cure certain leukemia types.
10. Clinical Trial Education: Inform patients about available clinical trials evaluating new leukemia therapies, discussing potential benefits and risks.
11. Implement Neutropenic Precautions: For patients with neutropenia (low neutrophil count), implement precautions to minimize infection risk:
- Meticulous hand hygiene for all healthcare providers and visitors.
- Private room isolation.
- Restriction of visitors who are ill.
- Avoidance of invasive procedures (rectal temperatures, suppositories).
- Limiting exposure to crowds and sick individuals.
- No fresh flowers or live plants in the room due to potential mold and bacteria.
12. Neutropenic Diet Education: If prescribed by the healthcare provider (though recent research questions its necessity), educate on neutropenic diet guidelines: avoid raw or undercooked foods, unpasteurized dairy, and ensure food safety practices.
13. Blood Transfusion Administration: Administer blood transfusions as ordered to manage anemia or bleeding symptoms, understanding they are supportive care and not a direct leukemia treatment.
14. Growth Factor Administration: Administer prescribed growth factors (e.g., Granulocyte Colony-Stimulating Factor, Erythropoietin, Thrombopoietin) to stimulate blood cell production, especially before stem cell harvesting for transplant.
15. Immunosuppressant Therapy: Provide immunosuppressants as ordered to prevent graft-versus-host disease post-stem cell transplant and manage side effects of cancer treatments.
16. Emphasize Urgent Medical Attention: Educate patients to seek immediate medical attention for any signs of infection, particularly fever ≥100.4°F (38°C), chills, new cough, sore throat, or signs of localized infection (redness, swelling, drainage). Neutropenic fever is a medical emergency.
17. Psychosocial and Emotional Support: Provide comprehensive support to patients and families, addressing the emotional, financial, and caregiving burdens associated with leukemia diagnosis and treatment. Offer resources and referrals as needed.
Leukemia Nursing Care Plans and Diagnoses
Nursing care plans are essential for structuring and prioritizing nursing care, based on identified nursing diagnoses. The following are examples of common nursing diagnoses in leukemia care.
Chronic Pain
Bone pain and neuropathic pain are common in leukemia patients.
Nursing Diagnosis: Chronic Pain
Related Factors:
- Disease process (bone marrow infiltration, lymphadenopathy)
- Chemical agents (chemotherapy-induced neuropathy)
Evidenced By:
- Verbal reports of pain
- Diaphoresis
- Distraction behaviors
- Guarding postures
- Pain intensity ratings
- Pain quality descriptions
Expected Outcomes:
- Patient will report reduced pain levels after pain medication administration.
- Patient will describe two nonpharmacologic pain management strategies.
Assessments:
- Comprehensive Pain Assessment: Detail pain location, intensity, quality, onset, duration, aggravating/relieving factors.
- Vital Signs and Nonverbal Cues: Monitor for pain-related vital sign changes (increased heart rate, blood pressure, respiratory rate) and nonverbal pain indicators (especially in children).
Interventions:
- Discuss Medical Marijuana Options: If legally permissible and appropriate, discuss marijuana or cannabinoid compounds for neuropathic pain relief and inflammation reduction.
- Offer Complementary Therapies: Integrate complementary therapies (meditation, yoga, acupuncture, nutritional support) for symptom management and pain relief.
- Nonpharmacologic Pain Relief: Provide comfort measures like massage, psychological support, diversional activities, heat/cold applications.
- Administer Pain Medications: Administer analgesics (including opioids for severe pain) and adjuvant medications as prescribed.
Fatigue
Leukemia and its treatments commonly cause significant fatigue.
Nursing Diagnosis: Fatigue
Related Factors:
- Disease process (anemia, metabolic demands)
- Pain
- Anemia
- Psychological stress
- Physical exertion
- Chemotherapy and other treatments
Evidenced By:
- Apathy and decreased motivation
- Difficulty maintaining physical activity
- Difficulty performing daily routines
- Drowsiness and increased sleep
- Expressed lack of energy
- Expressed tiredness or exhaustion
- Weakness
- Impaired role performance
- Exhaustion after minimal activity
- Increased rest or nap needs
Expected Outcomes:
- Patient will demonstrate strategies to manage fatigue and improve activity tolerance.
- Patient will report improved energy levels and ability to perform desired activities.
Assessments:
- Fatigue Severity Assessment: Use standardized fatigue scales to quantify fatigue impact on quality of life and daily functioning.
- Laboratory Value Monitoring: Assess CBC, electrolytes, and other relevant labs to identify contributing factors like anemia, infection, or treatment side effects.
Interventions:
- Encourage Verbalization of Feelings: Facilitate patient expression of feelings about fatigue and its impact to promote coping and realistic goal setting.
- Mental Health Support Referral: Suggest counseling or therapy to address psychological aspects of fatigue and develop coping strategies for “brain fog” and emotional distress.
- Encourage Assistance Seeking: Remind patients that it’s appropriate to seek help from family and friends with tasks to conserve energy.
- Planned Exercise Encouragement: Promote participation in planned, moderate exercise as tolerated to improve energy levels and physical function (within safe limits).
Risk for Decreased Cardiac Output
Leukemia and cancer treatments can increase cardiac risks.
Nursing Diagnosis: Risk for Decreased Cardiac Output
Related Factors:
- Leukemia cell infiltration of cardiac tissue
- Reduced oxygen supply to the heart
- Inflammation
- Immunosuppression
- Cardiotoxic cancer treatments (e.g., anthracyclines)
Evidenced By:
A risk diagnosis is not evidenced by signs and symptoms.
Expected Outcomes:
- Patient will maintain adequate cardiac output without developing heart failure, endocarditis, or pericarditis.
- Patient will exhibit stable cardiac rhythm on ECG.
- Patient will verbalize two strategies to promote cardiac health.
Assessments:
- Anthracycline Monitoring: If patient is receiving anthracyclines (e.g., doxorubicin, idarubicin), monitor for cardiac toxicity signs (changes in blood pressure, activity intolerance, dyspnea, chest pain, palpitations, edema).
- Echocardiogram Review: Review baseline and follow-up echocardiograms to assess left ventricular ejection fraction and cardiac function.
- ECG Monitoring: Obtain ECG if history of cardiac disease or new cardiac symptoms arise to monitor for dysrhythmias.
Interventions:
- Anthracycline Dose Discussion: If cardiac side effects occur with anthracyclines, collaborate with the healthcare team to consider dose reduction or alternative agents.
- Cardiology Referral: Consult with a cardiologist if cardiac issues develop or pre-exist.
- Medication Administration: Administer prescribed cardiac medications (ACE inhibitors, beta-blockers, diuretics) to manage heart failure manifestations.
- Lifestyle Modification Education: Educate on heart-healthy lifestyle changes: regular exercise, smoking cessation, healthy weight maintenance, limited alcohol intake, reduced saturated fat, salt, and cholesterol diet.
Risk for Imbalanced Fluid Volume
Leukemia and its treatments can disrupt fluid balance.
Nursing Diagnosis: Risk for Imbalanced Fluid Volume
Related Factors:
- Cancer treatments (chemotherapy)
- Infection or sepsis
- Blood transfusions
- Treatment/disease adverse effects (nausea, vomiting, diarrhea)
- Kidney injury
- Pre-existing cardiovascular or renal conditions
Evidenced By:
A risk diagnosis is not evidenced by signs and symptoms.
Expected Outcomes:
- Patient will maintain balanced fluid intake and output.
- Patient will remain free from signs of fluid imbalance (edema, mental status changes, hypotension, shortness of breath, dry mucous membranes).
- Patient’s hemoglobin, hematocrit, and electrolytes will remain within normal limits.
Assessments:
- Strict Fluid Intake and Output Monitoring: Accurately measure and record fluid intake and output each shift. Calculate daily fluid balance.
- Symptom Assessment for Fluid Deficit: Monitor for symptoms causing fluid loss (nausea, vomiting, diarrhea, fever, bleeding).
- Comorbidity Review: Identify pre-existing conditions (kidney disease, heart failure) that can impact fluid balance.
- Medication Review: Review medications that can affect fluid balance (diuretics, laxatives, NSAIDs, antihypertensives).
Interventions:
- Symptom Control: Administer antiemetics, antidiarrheals, and antipyretics as needed to manage symptoms causing fluid loss.
- Laboratory Monitoring: Closely monitor hemoglobin, hematocrit, coagulation studies, BUN, creatinine, and electrolytes for signs of fluid imbalance.
- Patient Education on Fluid Imbalance: Educate patient about dehydration and fluid overload symptoms and when to seek medical attention.
- Cautious Blood Product Administration: Administer blood transfusions judiciously to avoid fluid overload.
Risk for Infection
Immunosuppression increases infection risk in leukemia patients.
Nursing Diagnosis: Risk for Infection
Related Factors:
- Chemotherapy-induced immunosuppression
- Anemia
- Leukemia disease process
- Leukopenia (low white blood cell count)
Evidenced By:
A risk diagnosis is not evidenced by signs and symptoms.
Expected Outcomes:
- Patient will demonstrate infection prevention strategies and remain free from infection symptoms.
- Patient will not develop an infection.
Assessments:
- Risk Factor Assessment: Identify factors increasing infection susceptibility (age extremes, comorbidities, neutropenia).
- CBC Monitoring: Monitor CBC values, especially white blood cell count and neutrophil count, to assess infection risk.
Interventions:
- Isolation and Private Room: Consider private room placement, especially for neutropenic patients, to reduce pathogen exposure.
- Hand Hygiene Promotion: Emphasize meticulous handwashing for all healthcare providers, patients, and visitors.
- Infection Control Measures: Implement and reinforce infection control practices (aseptic technique, catheter care, oral hygiene, mask use in crowds).
- Antibiotic Administration: Administer prophylactic or therapeutic antibiotics as prescribed.
- Nutritional Support: Encourage a nutritious diet to support immune function; consult dietitian as needed.
References
Cancer Nursing Diagnosis & Care Plan
Smoking Nursing Diagnosis & Care Plan
Anorexia Nursing Diagnosis & Care Plan
Risk for Bleeding Nursing Diagnosis & Care Plan
Abdominal Pain Nursing Diagnosis & Care Plan
Headache Migraine Nursing Diagnosis & Care Plan
Anemia Nursing Diagnosis & Care Plan
Chemotherapy Nursing Diagnosis & Care Plan
Subjective vs. Objective Data in Nursing
Shortness of Breath Dyspnea Nursing Diagnosis & Care Plan
Hematuria Nursing Diagnosis & Care Plan
Nursing Interventions
Nausea Nursing Diagnosis & Care Plan
Constipation Nursing Diagnosis & Care Plan
Diarrhea Nursing Diagnosis & Care Plan
Blood Transfusion Nursing Diagnosis & Care Plan
Nursing Diagnosis Guide
Nursing Care Plans Library
Chronic Pain Nursing Diagnosis & Care Plan
Hypertension Nursing Diagnosis & Care Plan
Fatigue Nursing Diagnosis & Care Plan
Heart Failure Nursing Diagnosis & Care Plan
Decreased Cardiac Output Nursing Diagnosis & Care Plan
Activity Intolerance Nursing Diagnosis & Care Plan
Chest Pain Angina Nursing Diagnosis & Care Plan
Edema Nursing Diagnosis & Care Plan
Fluid Volume Deficit Nursing Diagnosis & Care Plan
Altered Mental Status Nursing Diagnosis & Care Plan
Hypotension Nursing Diagnosis & Care Plan
Acute Kidney Injury Nursing Diagnosis & Care Plan
Risk for Electrolyte Imbalance Nursing Diagnosis & Care Plan
Risk for Infection Nursing Diagnosis & Care Plan
Neutropenia Nursing Diagnosis & Care Plan
