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Leukemia

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Overview

  1. Proliferation of abnormal, undeveloped WBCs
    1. Unable to function in infection control / immunity
  2. Diagnosed by blood tests and bone marrow biopsy

Nursing Points

General

  1. Characterized by type of WBC affected
    1. Acute Lymphocytic Leukemia (ALL)
      1. 2-4 years of age
    2. Chronic Lymphocytic Leukemia (CLL)
      1. 50-70 years of age
    3. Acute Myelogenous Leukemia (AML)
      1. Peak at 60 years of age
    4. Chronic Myelogenous Leukemia (CML)
      1. Incidence increases with age

Assessment

  1. Weight loss
  2. Fever
  3. Infections
  4. Pain in bones and  joints
  5. Night sweats
  6. Aplastic Anemia
    1. Pallor
    2. Fatigue
    3. Easy bleeding and bruising
  7. ↑ WBC in CLL and CML
  8. ↓ WBC in ALL and AML
  9. Philadelphia chromosome in majority of CML clients
  10. Mouth sores from chemo

Therapeutic Management

  1. Chemotherapy and radiation
  2. Bone Marrow Biopsy
    1. Apply pressure to biopsy site
    2. Provide analgesia
  3. Initiate neutropenic precautions
    1. Strict hand washing
    2. Limit visitation
    3. No fresh fruits or flowers
  4. Initiate bleeding precautions
  5. Avoid fatigue
  6. Plan activities to provide time for rest
  7. Instruct client on oral hygiene
    1. Rinse mouth with saline
    2. Avoid lemon, alcohol based mouthwash

Nursing Concepts

  1. Cellular Regulation
  2. Infection Control
  3. Comfort
  4. Clotting

Patient Education

  1. Bleeding Precautions
  2. Infection Precautions
  3. Oral Hygiene

Reference Links

Study Tools

Video Transcript

In this lesson we’re going to talk specifically about Leukemia. You may or may not have heard of this before nursing school, but we’re gonna break it down for you and give you the most important things you need to know.

Leukemia is a cancer of the bone marrow. Remember that the bone marrow is responsible for creating all of our blood cells, including red blood cells and platelets, but Leukemia primarily affects our White Blood Cells. As the cancer takes over, we begin to see excessive white blood cell production. The problem is that they are abnormal, immature, undeveloped cells. So they can’t actually perform the normal functions of a White Blood Cell. What does a white blood cell do? Well it’s entirely responsible for our immune system and fighting off infection. Without properly functioning white blood cells, you will not be able to fight off infections or heal wounds or anything of the sort. You can also see here how the shift towards excessive production of white blood cells can also hinder the production of red blood cells and platelets.

So how do we diagnose leukemia. Well we’ll first see the clinical picture, which you’ll see in a second could be pretty non-specific. But when we check a CBC and we get a White Blood Cell count with differential, we start to see this excessive production of these immature cells. What do I mean by differential? Well, remember you have multiple types of white blood cells. It starts as a stem cell and splits into either a myeloid cell or a lymphoid cell. Lymphoid cells become our lymphocytes, which are powerful infection fighters. Myeloid cells develop into red blood cells, platelets, and our other 4 types of white blood cells – basophils, neutrophils, eosinophils, and monocytes. So, the differential breaks these down into percentages – how many of the white blood cells are neutrophils versus lymphocytes, etc. Now, this only gives us a hint that something might be going on, so we also have to do a bone marrow biopsy – this allows us to see the actual cancer cells within the bone marrow to make an official diagnosis based on which type of cell is affected.

There’s lymphocytic leukemia which affects the lymphoid cells, and myelogenous leukemia which affects these myeloid cells. And both can be split into acute or chronic. Acute Lymphocytic Leukemia or ALL is most common in children under the age of 15. Chronic Lymphocytic Leukemia or CLL is most common in the elderly, usually 50-70 years old. Acute Myelogenous Leukemia or AML also peaks at about 60 years old. And Chronic Myelogenous Leukemia or CML can affect anyone, but the risk will increase with age. Generally speaking, the Acute forms are more serious than Chronic, and AML is more serious than ALL and it is the most common form.

When it comes to symptoms of Leukemia – they’re very non-specific and generalized, but there’s a few things that when you put them together it should click to you that something’s up. They’ll have weight loss, fevers, and frequent infections, as well as night sweats. Again, pretty general, right? But – combine it with these next few and a lightbulb should go off. They’re going to have pain in their bones and joints – why? Because it’s cancer of the bone marrow – so those bones are going to be achy. Because the bone marrow isn’t functioning properly, we can also see aplastic anemia – where they aren’t producing red blood cells or platelets as well either – so they are weak, pale, fatigued, and they will bleed or bruise easily. I’m telling you – the most common thing that happens is people feel these flu-like symptoms – fever, body aches, etc. – like they can’t shake it – and then suddenly they start seeing bruises pop up. And they don’t go away. They’ll bump into something really gently and a massive bruise shows up. That’s usually what gets people to start looking into it and going to see their doctor. Now, in Chronic leukemias we see overall elevated white blood cell counts, but in Acute leukemias we can see the counts drop as more and more of the bone marrow is affected quickly.

The primary treatment for leukemia is going to be chemotherapy and possibly radiation. Later in treatment, some patients may also be eligible for a bone marrow transplant. The primary purpose of chemotherapy is to target and kill those fast-growing cells. The problem is, it also kills fast-growing healthy cells like hair follicles and mucous membranes – so they can have quite a few side effects like nausea and vomiting, hair loss, and mouth sores – people may even call it chemo mouth. Because of this lack of functioning blood cells, we need to put them on neutropenic precautions. Now, the CDC says we don’t need to do reverse isolation – where we wear a mask and gown to protect the patient – we just use standard precautions, but we also limit visitors, especially sick ones, and we don’t allow fresh fruit or flowers – there’s too much risk for infection. We also use bleeding precautions because of the low platelets, provide frequent rest periods because of the extreme fatigue, and do really good oral care – especially from the chemo mouth. Open sores in the mouth are a HUGE source of infection getting into the bloodstream, so oral hygiene is a must for leukemia patients.

Priority nursing concepts for a patient with Leukemia are cellular regulation, infection control, and clotting. We need to support them through their chemo or bone marrow transplant, prevent infection, and use bleeding precautions to prevent injury. Check out the care plan attached to this lesson to see more detailed nursing interventions and rationales.

So let’s recap – Leukemia is a cancer of the bone marrow that results in proliferation or excessive production of immature, undeveloped, non-functioning white blood cells. It’s classified based on whether it affects the myeloid or lymphoid cells and whether it’s acute or chronic, with AML being the most common and the more severe. Patients will be at high risk of infection and will be weak, tired, achy and will experience aplastic anemia – so they’ll be pale and will bruise or bleed easily. We treat this with chemo and radiation, or a bone marrow transplant if the patient is eligible. Just remember that chemo ALSO kills fast-growing healthy cells, so patients will experience quite a few symptoms. We want to support them through that, prevent infection with neutropenic precautions and really good hand hygiene, put them on bleeding precautions, and take good care of their oral health.

So those are the basics of Leukemia, use all of the resources within this lesson to learn more, including the care plan and case study. Now, go out and be your best selves today. And, as always, happy nursing!

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