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Leukemia is a type of cancer which affects the blood cells. This entails the proliferation of abnormal immature white blood cells. These cells are accumulated in the lymphoid tissues and bone marrow, and when a person have leukemia it reproduce uncontrollably and infiltrate the body tissues and blood vessels. This will eventually lead to malfunction due to hemorrhage, encroachment, or infection. This can be further classified as acute, which is rapidly growing; or chronic, which develops more gradually.

leukemia-nursing-care-plan

Type of Leukemia

Acute – this type of leukemia entails a profound percentage of such immature cells and tends to progress rapidly if chemotherapy is not provided. In fact, the case of acute leukemia is already considered as a medical emergency, which would often require hospitalization and initiation of therapy within hours of the time and diagnosis is made.

Chronic – this condition has a lower percentage of immature cells and also have a significantly higher proportion of mature cells. Unlike acute type, this condition may progress slowly and may also not cause manifestations for years.

  • The percentage of immature cells and the proportion of mature cells, determines the distinction between acute leukemia and chronic leukemia; instead of the number of abnormal cells found in the blood or the bone marrow.

Aside from acute and chronic leukemia, leukemia can be further identified as lymphocytic/ lymphoblastic or myelogenous.

Lymphocytic/ Lymphoblastic – affects the white blood cells referred as lymphocytes.

Myelogenous – affects the white blood cells referred as myelocytes.

Signs and Symptoms

  • Loss of appetite
  • Weight loss
  • Fatigue
  • Fever
  • Bleeding
    • Bleeding gums
    • Red spots on the skin
    • Widespread bruising
    • Frequent or severe nose bleeds
    • Petechiae
  • Anemia
    • Paleness
    • Malaise
    • Dizziness
    • Shortness of breath
    • Rapid heartbeat
  • Frequent infections
    • Cold sores
    • Urinary tract
    • Pneumonia
    • Gums
    • Infection in the anal area
  • Headache
  • Vomiting
  • Sore throat
  • Bone or joint pain
  • Night sweats
  • Swelling of the testicles
  • Vision problems
  • Abdominal discomfort or feeling of fullness
  • Bone or joint pain
  • Enlarged lymph nodes

Treatment

  • Stem cell transplant: an option is recommended for patient age 55 years old.
  • Chemotherapy: this option is often the main treatment for patients with leukemia and other forms of cancer.
  • Radiation therapy: most often use in preventing spread to the central nervous system as well as for treating the disease per se; and to prepare for stem cell transplant.
  • Targeted therapy: a treatment used for patients with Philadelphia treatment.
  • Supportive therapy: an intervention used for managing complications of treatment.

Supportive Care for Leukemia

Fatigue: this is a known symptoms when a patient have a low red blood cells, and this may require blood transfusion.

Infection: this develops due to low white blood cell count (neutropenia). Neutropenia is brought about by malfunction of bone marrow, or could be an effect of the chemotherapy treatment. Medications used for this symptoms are antibiotics and antifungal.

Abnormal bleeding: this transpire due to low platelet count. This is also brought about by malfunction of bone marrow, or could be an effect of the chemotherapy treatment. The treatment provided for this symptom is platelet transfusion to help slow or reduce bleeding.

Loss of appetite: this is a common symptoms for patients with leukemia, and it could result from the disease per se, fatigue or depression, and treatments.

Emotional health: during treatment, the patient may experience vast array of overwhelming emotions. Unexpected feelings or thoughts felt by the patients may include the following:

  • Adapting to lifestyle
  • Concern that the cancer will come back
  • Thinking about the possible effects of cancer to them, their family, friends, work, and other significant others.
  • Anxiety due to less contact with the health care team
  • Questioning self- worth, identity, and alterations in appearance

Diagnostic Studies

Carcinoembryonic antigen (CEA): May be elevated.

Cold agglutinins: May be elevated (more than 1:16) in lymphatic leukemia.

Cryoglobulins: Positive cryoglobulin findings may be present in patients with lymphocytic leukemia.

CBC: Indicates a normocytic, normochromic anemia.

Hemoglobin: May be less than 10 g/100 mL.

Reticulocytes: Count is usually low.

Platelet count: May be 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): Prolonged.

LDH: May be elevated.

Serum/urine uric acid: May be elevated.

Serum muramidase (a lysozyme): Elevated in acute monocytic and myelomonocytic leukemias.

Serum copper: Elevated.

Serum zinc: Decreased.

Bence Jones protein (urine): 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 x-ray and lymph node biopsies: May indicate degree of involvement.

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 psychological support.
  6. Provide information about disease process/prognosis and treatment needs.

Nursing Care Plans for Leukemias (Based on NANDA)

Nursing diagnosis: Infection, risk for

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—patient will:

Knowledge: Infection Control (NOC)

  • Identify actions to prevent/reduce risk of infection.
    Demonstrate techniques, lifestyle changes to promote safe environment, achieve timely healing.
Nursing InterventionsRationale
Infection Protection

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.

Protect patient from potential sources of pathogens/infection. Note: Profound bone marrow suppression, neutropenia, and chemotherapy place patient at great risk for infection.
Require good handwashing protocol for all personnel and visitors.Prevents cross-contamination/reduces risk of infection.
Monitor temperature. Note correlation between temperature elevations and chemotherapy treatments. Observe for fever associated with tachycardia, hypotension, subtle mental changes.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 patients. Note: Septicemia may occur without fever.
Prevent chilling. Force fluids, administer tepid sponge bath.Helps reduce fever, which contributes to fluid imbalance, discomfort, and CNS complications.
Encourage frequent turning and deep breathing.Prevents stasis of respiratory secretions, reducing risk of atelectasis/pneumonia.
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.Early intervention is essential to prevent sepsis/septicemia in immunosuppressed person.
Handle patient gently. Keep linens dry/wrinkle-free.Prevents sheet burn/skin excoriation.
Inspect skin for tender, erythematous areas; open wounds. Cleanse skin with antibacterial solutions.May indicate local infection. Note: Open wounds may not produce pus because of insufficient number of granulocytes.
Inspect oral mucous membranes. Provide good oral hygiene. Use a soft toothbrush, sponge, or swabs for frequent mouth care.The oral cavity is an excellent medium for growth of organisms and is susceptible to ulceration and bleeding.
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.Promotes cleanliness, reducing risk of perianal abscess; enhances circulation and healing. Note: Perianal abscess can contribute to septicemia and death in immunosupressed patients.
Coordinate procedures and tests to allow for uninterrupted rest periods.Conserves energy for healing, cellular regeneration.
Encourage increased intake of foods high in protein and fluids with adequate fiber.Promotes healing and prevents dehydration. Note: Constipation potentiates retention of toxins and risk of rectalirritation/tissue injury.

 

Nursing InterventionRationale
Infection Protection 

Independent

Avoid/limit invasive procedures (e.g. venipuncture and injections) as possible.

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.
Collaborative

Monitor laboratory studies, e.g.:

CBC, noting whether WBC count falls or sudden changes occur in neutrophils;

Decreased numbers of normal/mature WBCs can result from the disease process or chemotherapy, compromising the immune response and increasing risk of infection.
Gram’s stain cultures/sensitivity.Verifies presence of infections; identifies specific organisms and appropriate therapy.
Review serial chest x-rays.Indicator of development/resolution of respiratory complications.
Prepare for/assist with leukemia-specific treatments such as chemotherapy, radiation, and/or bone marrow transplant.Leukemia is usually treated with a combination of these agents, each requiring specific safety precautions for patient and care providers.
Administer medications as indicated, e.g.: antibiotics;May be given prophylactically or to treat specific infection.
Colony-stimulating factors: sargramostim (Leukine).Restores WBCs destroyed by chemotherapy and reduces risk of severe infection and death in certain types of leukemia.
Avoid use of aspirin-containing antipyretics.Aspirin can cause gastric bleeding and further decrease platelet count.
Provide nutritious diet, high in protein and calories, avoiding raw fruits, vegetables, or uncooked meats.Proper nutrition enhances immune system. Minimizes potential sources of bacterial contamination.

Nursing diagnosis: Fluid Volume, risk for deficient

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—patient will:

  • Demonstrate adequate fluid volume, as evidenced by stable vital signs; palpable pulses; urine output, specific gravity, and pH within normal limits.
  • Identify individual risk factors and appropriate interventions.
  • Initiate behaviors/lifestyle changes to prevent development of dehydration.
Nursing InterventionRationale
Fluid Management

Independent

Monitor I&O. Calculate insensible losses and fluid balance. Note decreased urine output in presence of adequate intake. Measure specific gravity and urine pH.

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.
Weigh daily.Measure of adequacy of fluid replacement and kidney function. Continued intake greater than output may indicate renal insult/obstruction.
 

Monitor BP and HR.

Changes may reflect effects of hypovolemia (bleeding/dehydration).
Evaluate skin turgor, capillary refill, and general condition of mucous membranes.Indirect indicators of fluid status/hydration.
Note presence of nausea, fever. 

Affects intake, fluid needs, and route of replacement.

Encourage fluids of up to 3–4 L/day when oral intake is resumed.Promotes urine flow, prevents uric acid precipitation, and enhances clearance of antineoplastic drugs.
Nursing InterventionRationale
Bleeding Precautions

Independent

Inspect skin/mucous membranes for petechiae, ecchymotic areas; note bleeding gums, frank or occult blood in stools and urine; oozing from invasive-line sites.

Suppression of bone marrow and platelet production places patient at risk for spontaneous/uncontrolled bleeding.
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 and avoiding sharp razors when shaving; avoiding forceful nose blowing and needlesticks when possible; using sustained pressure (sandbags or pressure dressings) on oozing puncture/IV sites.Fragile tissues and altered clotting mechanisms increase the risk of hemorrhage following even minor trauma.
Limit oral care to mouthwash if indicated (a mixture of 1/4 tsp baking soda or salt in 4–8 oz water or hydrogen peroxide in water). Avoid mouthwashes with alcohol.When bleeding is present, even gentle brushing may cause more tissue damage. Alcohol has a drying effect and may be painful to irritated tissues.
Provide soft diet.May help reduce gum irritation.
Fluid Management

Collaborative

Administer IV fluids as indicated.

Maintains fluid/electrolyte balance in the absence of oral intake; prevents or minimizes tumor lysis syndrome, reduces risk of renal complications.
Administer medications as indicated, e.g.

Antiemetics: 5-HT3 receptor antagonist drugs such as ondansetron (Zofran) or granisetron (Kytril)

Relieves nausea/vomiting associated with administration of chemotherapy agents.
Allopurinol (Zyloprim)Improves renal excretion of toxic byproducts from breakdown of leukemia cells. Reduces the chances of nephropathy as a result of uric acid production.
Potassium acetate or citrate, sodium bicarbonateMay be used to alkalinize the urine, preventing or minimizing tumor lysis syndrome/kidney stones.
Stool softeners.Helpful in reducing straining at stool with trauma to rectal tissues.
Bleeding Precautions

Monitor laboratory studies, e.g. platelets, Hb/Hct, clotting.

When the platelet count is less than 20,000/mm (because of proliferation of WBCs and/or bone marrow suppression secondary to antineoplastic drugs), patient is prone to spontaneous life-threatening bleeding. Decreasing Hb/Hct is indicative of bleeding (may be occult).
Collaborative

Administer RBCs, platelets, clotting factors.

Restores/normalizes RBC count and oxygen-carrying capacity to correct anemia. Used to prevent/treat hemorrhage.
Maintain external central vascular access device (subclavian or tunneled catheter or implanted port).Eliminate peripheral venipuncture as source of bleeding.
Administer medications, e.g. oral contraceptivesMinimizes blood loss by stopping or slowing menstrual flow.

Nursing diagnosis: Pain, acute

May be related to

  • Physical agents, e.g. enlarged organs/lymph nodes, bone marrow packed with leukemic cells
  • Chemical agents, e.g. antileukemic treatments
  • Psychological 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—patient will:

Pain Level (NOC)

  • Report pain is relieved/controlled.
  • Appear relaxed and able to sleep/rest appropriately.

Pain Control (NOC)

  • Demonstrate behaviors to manage pain.
Nursing InterventionRationale
Pain Management

Independent

Investigate reports of pain. Note changes in degree (use scale of 0–10) and site.

 

Helpful in assessing need for intervention; may indicate developing complications.

Monitor vital signs, note nonverbal cues, e.g. muscle tension, restlessness.May be useful in evaluating verbal comments and effectiveness of interventions.
Provide quiet environment and reduce stressful stimuli, e.g. noise, lighting, constant interruptions.Promotes rest and enhances coping abilities.
Place in position of comfort and support joints, extremities with pillows/padding.May decrease associated bone/joint discomfort.
Reposition periodically and provide/assist with gentle ROM exercises.Improves tissue circulation and joint mobility.
Provide comfort measures (e.g. massage, cool packs) and psychological support (e.g. encouragement, presence).Minimizes need for/enhances effects of medication.
Review/promote patient’s own comfort interventions, e.g. position, physical activity/nonactivity, and so forth.Successful management of pain requires patient involvement. Use of effective techniques provides positive reinforcement, promotes sense of control, and prepares patient for interventions to be used after discharge.
Evaluate and support patient’s coping mechanisms.Using own learned perceptions/behaviors to manage pain can help patient cope more effectively.
Encourage use of stress management techniques, e.g. relaxation/deep-breathing exercises, guided imagery, visualization; Therapeutic Touch.Facilitates relaxation, augments pharmacological therapy, and enhances coping abilities.
Assist with/provide diversional activities, relaxation techniques.Helps with pain management by redirecting attention.
Collaborative

Monitor uric acid level as appropriate.

Rapid turnover and destruction of leukemic cells during chemotherapy can elevate uric acid, causing swollen painful joints in some patients. Note: Massive infiltration of WBCs into joints can also result in intense pain.
Administer medications as indicated:

Analgesics, e.g. acetaminophen (Tylenol)

Given for mild pain not relieved by comfort measures. Note: Avoid aspirin-containing products because they may potentiate hemorrhage.
Opioids, e.g., codeine, morphine, hydromorphone (Dilaudid);Used 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 patient’s sense of control.
Antianxiety agents, e.g., diazepam (Valium), lorazepam (Ativan). 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—patient 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 patient’s normal range.
Nursing InterventionRationale
Energy Management 

Independent

Evaluate reports of fatigue, noting inability to participate in activities or ADLs.

Effects of leukemia, anemia, and chemotherapy may be cumulative (especially during acute and active treatment phase), necessitating assistance.
Encourage patient to keep a diary of daily routines and energy levels, noting activities that increase fatigue.Helps patient prioritize activities and arrange them around fatigue pattern.
Provide quiet environment and uninterrupted rest periods. Encourage rest periods before meals.Restores energy needed for activity and cellular regeneration/tissue healing.
Implement energy-saving techniques, e.g., sitting, rather than standing, use of shower chair. Assist with ambulation/other activities as indicated.Maximizes available energy for self-care tasks.
Schedule meals around chemotherapy. Give oral hygiene before meals and administer antimetics as indicated.May enhance intake by reducing nausea.
Recommend small, nutritious, high-protein meals and snacks throughout the day.Smaller meals require less energy for digestion than larger meals. Increased intake provides fuel for energy.
Collaborative

Provide supplemental oxygen.

Maximizes oxygen available for cellular uptake, improving tolerance of activity.

Nursing diagnosis: Knowledge, deficient [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—patient 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.
Nursing InterventionRationale
Teaching: Disease Process (NIC)

Independent

Review pathology of specific form of leukemia and various treatment options.

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

References

  • Canobbio, M. (2006). Mosby’s handbook of patient teaching. Elsevier Health Sciences
  • Leukemia. (2015). Canadian Cancer Society. Retrieved October 27, 2015 from http://www.cancer.ca/en/cancer-information/cancer-type/leukemia/leukemia/?region=on.
  • Markman, M., Loguidice, C. & Lammersfeld, C. (2013). Cancer nutrition and recipes for dummies. Hoboken, NJ: John Wiley & Sons.
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Danica is a Registered Nurse in the Philippines who used to work as an Occupational Health Nurse in a pharmaceutical company. She opted to devote and exemplify her profession through writing. She is an Academic Writer for more than three years. A mother of adorable 5 year old girl and an entrepreneur who started designing and making customized and originally crafted bags.