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.
CARE SETTING
Acute inpatient care on medical unit for initial evaluation and treatment typically 4–6 wk, then at the community level.
RELATED CONCERNS
Cancer
Psychosocial aspects of care
Transplantation: postoperative and lifelong needs
Patient 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
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 distension, 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 alkalating 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
DRG projected mean length of inpatient stay: 7.4–9.3 days
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
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.
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 patient teaching.
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.
CARE SETTING
Acute inpatient care on medical unit for initial evaluation and treatment typically 4–6 wk, then at the community level.
RELATED CONCERNS
Cancer
Psychosocial aspects of care
Transplantation: postoperative and lifelong needs
Patient 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
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 distension, 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 alkalating 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
DRG projected mean length of inpatient stay: 7.4–9.3 days
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
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.
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 patient teaching.
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