NURS3144 Nursing in The Hospital II

Nursing Care of Clients with

Hematological Disorders: Leukemia
and Bone Marrow Transplant

eLearning
 Learning Outcomes

At the end of this lecture, students would be able to:

 Describe etiology, pathophysiology, and clinical manifestations
of leukemia.
 Identify different types of leukemia.
 Describe diagnostic tests of leukemia.
 Discuss the treatment and management of clients with
leukemia.
 Identify the nursing diagnoses and nursing intervention of
clients with leukemia.
 Leukemia

 Referred to as “white blood”.

 A group of malignant disorders of WBCs and their precursors.
 Ratio reversed: WBC > RBCs.
 Unregulated proliferation of leukocytes in bone marrow 
premature release of cells into circulation (leukocytosis).
 Deranged immature cells:
◦ Accumulate in bone marrow and blood  little space for normal cell
production  pancytopenia.
◦ Accumulate within organs (e.g. liver, spleen, and lymph nodes).
◦ Blood cells unable to carry out normal functions.
 Etiology of Leukemia

 Cause not fully known.

 Men > females.
 Some leukemia are caused by retrovirus, human T-cell
leukemia or lymphocyte virus-1 (HTLV-1).
 Genetic disorders (e.g. Down syndrome).
 Exposure to ionizing radiation.
 Chemical exposure (e.g. Benzene, cigarette smoking).
 Pathophysiology
 Malignant transformation of stem cells.
 Abnormal leukemic cells accumulate in bone marrow.
◦ Compete proliferation with normal cells.
◦ Anemia, neutropenia, thrombocytopenia.
 Immature WBCs develop.
◦ Ineffective in inflammatory and immune response.
 Leukemic cells leave bone marrow and travel through circulatory
system  increase number of leukocytes in blood.
◦ Infiltrate other body tissues. e.g. CNS, testes, skin, GI tract, lymph
nodes, liver, and spleen.
 Death is usually due to internal hemorrhage and infections.
 General Clinical Manifestations
Clinical Manifestation Signs and Symptoms
Neutropenia •Infection •Night sweats
•Fever •Oral ulcerations
Thrombocytopenia •Bruising •Bleeding gums
•Petechiae •Bleeding within tissues
and organs
Anemia •Pallor •Dyspnea
•Malaise
Increased proliferation •Hepatomegaly •Lymphadenopathy
•Splenomegaly •Bone pain
Meningeal infiltration •Headache •Nausea & vomiting
•Decreased level of
consciousness
Increased metabolism •Weight loss •Heat intolerance
•Tachycardia
Multi-System Effects of Leukemia

Taken from: LeMone,

Burke, & Bauldoff (2011).
 Classification of Leukemia (1)

 Classification is based on:

1. Acuity
 Acute
◦ Abrupt onset, rapid disease progression, and immature blast cells.

 Chronic
◦ Gradual onset, prolonged course with abnormal mature cells.
 Classification of Leukemia (2)

2. Stem cell involvement

 Myeloid cell
◦ Myeloid leukemia.
◦ Interfere with maturation of all types of blood cells.

 Lymphoid cell
◦ Lymphoid leukemia.
◦ Involve immature lymphocytes and precursor cells.
 4 Types of Leukemia

Acute
Lymphocytic
Leukemia (ALL)
Acute
Acute Myeloid
Leukemia (AML)
Leukemia
Chronic
Lymphocytic
Leukemia (CLL)
Chronic
Chronic Myeloid
Leukemia (CML)
(Cancer Research UK, 2003)
 Features of Leukemia

AML CML ALL CLL

Nature Uncontrolled Abnormal Uncontrolled Proliferation of
proliferation of proliferation of proliferation of small,
myeloblasts all bone immature abnormal,
marrow lymphoblasts mature
elements lymphocytes
Commonly Adult Older adult Children Older adult
Affected
population
Survival rate/ < 65 yrs: 33% Life 5-year survival average
life expectancy survival expectancy rate: survival ～ 7
about 3 – 5 years
> 65 yrs: 4 % 80% for
years
survival children
40% for adults
 Diagnostic Tests

 CBC with differentials:

◦ ↓ RBC
◦ ↓ Hb
◦ ↓ Hct
◦ ↓ Platelets
◦ ↑ WBC

 Morphology of WBCs.
 Bone marrow examination:
◦ Identify type of erythropoiesis, maturity of erythropoietic and
leukopoietic cells.
 Diagnostic Findings by Type of Leukemia
Test AML CML ALL CLL
RBC count Low Low Low Low
Hb Low Low Low Low
Hct Low Low Low Low
Platelet V. low High (early) Low Low
Low (late)
WBC Varies Increased Varies Increased
Myeloblasts Present
Neutrophils Decreased Increased Decreased
Lymphocytes Normal
Monocytes Normal/Low Increased
Blasts Present Present (crisis) Present
Bone marrow Hypercellular
Myeloblasts Present
Lymphoblasts Present
Lymphocytes Present
 Treatment

Objective: Focus on achieving remission or cure and relieving

symptoms.
1. Chemotherapy
2. Radiation therapy
3. Bone marrow transplant
4. Stem cell transplant
5. Biologic therapy
 Treatment:
1. Chemotherapy
 Single agent or combination chemotherapy is treatment of
choice for most types of leukemia.
 Induction phase:
◦ Eradicate leukemic cells including normal stem cells.
◦ Neutropenic, anemic, thrombocytopenic.
◦ Supportive care  administer blood products.
◦ Colony-Stimulating Factors (CSF) administered to “rescue” bone
marrow following induction phase  fever, chills, anorexia, muscle
aches, lethargy.
 Treatment:
1. Chemotherapy (con’t)
 Postremission therapy (a.k.a. consolidation therapy):
◦ Eliminate residual leukemic cells.
◦ Prevent recurrence, relapse, prolong survival.
◦ Single chemotherapeutic agent, combination therapy, or bone
marrow transplant used.
 Treatment:
2. Radiation therapy
 Radiation therapy damage cellular DNA.
 Cells can continue to function, but cannot divide and multiple.
 Bone marrow and cancer cells respond to radiation therapy.
 Unlike cancer cells, normal calls can recover from damage by
radiation therapy.
 Treatment:
3. Bone Marrow Transplant
 Bone marrow transplant (BMT) is treatment of choice for some
leukemia.
 Used in conjunction with chemotherapy and radiation therapy.
 2 types:
◦ Allogeneic BMT  from healthy donor.
◦ Autologous BMT  from own bone marrow.

 Management of Allogeneic BMT:

◦ Immunosuppression  Strict reverse-barrier nursing.
◦ Antimicrobial therapy  prevent infections.
◦ Observe complications e.g. malnutrition, infection, and bleeding.
 Treatment:
4. Stem Cell Transplant
 Alternative to BMT.
 Replacement of client’s blood cell lines (WBC, RBC, and
platelets) with cells from donor’s hematopoietic stem cells.
 Donors have to be closely matched with recipient.
 Risk for infection and other complications e.g. graft-versus-host
disease.
 What is Graft-Versus-Host Disease?

 Important implications to allogenic BMT and allogenic stem cell

transplant.
 T-lymphocytes recognize host body as “foreign” and attack body.
 Human Leukocyte Antigen (HLA) matched donors can improve long-
term survival.
◦ But, still risky and have high mortality if transplant fails.

 S/S: extensive erythematous skin rashes, diarrhea, GI bleed, liver

damage.
 Treatment: antibiotics, steroids, immunosuppressant drugs e.g.
thalidomide and XomaZyme.
 General Nursing Management
of BMT and Stem Cell Transplantation
Initial post-transplant care:
 Monitor vital signs, lab results, and signs of infections (e.g. fever,
chills).
 Nursing assessment: check for maculopapular rash, diarrhea,
abdominal pains, jaundice.
 Strict reverse barrier nursing  isolation room.
 Administer immunosuppressants and antimicrobial therapies.
Later post-transplant care:
 Assess for late side effects e.g. varicella zoster infection and
pneumonia.
 Treatment:
5. Biologic Therapy
 Using cytokines (e.g. interferons and interleukins) to regulate
growth of cells in treatment.
 To modify body’s response to cancer cells.
 Side effects: flu-like symptoms, persistent fatigue and lethargy,
anorexia, muscle and joint pains.
 Nursing Assessment
Health history: Physical examination:
 Fatigue  Skin and mucous membrane
 Exertional dyspnea ◦ Bruising, purpura, petechiae,
 Sore throat ulcers or lesions, pallor.

 Night sweats  Vital signs

 Bleeding gums, nosebleeds ◦ Orthostatic hypotension, heart

 Recent weight loss and lung sounds.

 Exposure to ionizing radiation or  Abdominal exam

chemicals ◦ Tender spleen, liver

 History of immune disorder ◦ Stools for occult blood

 Prior treatment for cancer

 Nursing Diagnoses

 Risk for infection.

 Imbalanced nutrition: less than body requirements.

 Impaired oral mucous membrane.

 Ineffective protection.

 Anticipatory grieving.
 Risk for Infection (1)

 Promptly report signs of infection.

◦ E.g. fever, chills, sore throat, cough, dysuria, purulent discharge.

 Maintain protective isolation as indicated.

 Ensure meticulous hand hygiene among all people in contact
with client.
 Restrict visitors with cold, flu, or infections.
 Provide oral hygiene after each meal.
 Avoid invasive procedures, use strict aseptic techniques.
 Risk for Infection (2)

 Monitor vital signs Q4H.

 Monitor neutrophil levels:
◦ No risk: 2,000 – 2,500 mm3
◦ Minimal risk: 1,000 – 2,000 mm3
◦ Moderate risk: 500 – 1,000 mm3
◦ Severe risk: < 500 mm3

 Explain infection precautions and restrictions.

 Imbalanced Nutrition: Less Than Body
Requirements
 Monitor weight regularly.
 Provide oral care before and after meals.
 Discuss dietary needs with dietician to ensure adequate intake
of nutrients necessary for health and tissue repair.
 Offer small low-fat, high-calorie meals and 5 – 8 glasses of
water daily.
 Offer nutritional supplements if necessary e.g. Ensure.
 Impaired Oral Mucous Membrane

 Monitor for swelling, ulcers, or lesions inside oral cavity.

 Obtain cultures for oral lesions.
 Use saline mouthwash.
 Apply petroleum jelly to lips.
 Use soft-bristle toothbrush.
 Avoid acidic fruit juices, spicy foods, crusty food, very hot or
cold food.
 Ineffective Protection (1)

Observe for and report signs of bleeding:

 Skin: petechiae, ecchymoses, and purpura.
 Gums, nasal membranes, and conjunctiva: bleeding
 Vomitus, stool, urine: visible or occult blood.
 Vaginal bleeding.
 Prolonged bleeding from puncture sites.
 Neurologic changes: headaches, visual changes, altered mental
status, ↓ loss of consciousness, seizures.
 Abdominal pain: epigastric pain, diminished bowel sounds, increasing
abdominal girth, rigidity, guarding.
 Ineffective Protection (2)

 Avoid invasive diagnostic procedures e.g. biopsy or lumbar

puncture.
 Apply pressure to injection sites for 3 – 5 mins and arterial sites
for 15 – 20 mins.
 Avoid:
◦ Forcefully blowing or picking nose.
◦ Forcefully coughing or sneezing.
◦ Straining on bowel movement.

 Maintain adequate hydration.

 Anticipatory Grieving

 Assess usual coping strategies.

 Assist to identify sources of strength and support.
 Discuss changing roles and its effect on spiritual, social,
economic status, and usual lifestyle.
 Use therapeutic communication skills to facilitate open
discussion.
 Provide information about support groups e.g. Hong Kong Blood
Cancer Foundation (non-profit charity organization).
 Patient Education

 Provide knowledge about leukemia

◦ Usual course of leukemia.
◦ Treatment options and side effects of treatment.

 Teach how to prevent infection and injury

◦ Emphasize on meticulous personal hygiene.
◦ Avoid crowds.
◦ Eat cooked fruits and vegetables (not raw).
◦ Maintain good oral hygiene.
◦ Report any signs of infection or bleeding promptly.
 Additional Resources

 Information on graft-versus-host disease:

http://www.cancerresearchuk.org/about-cancer/coping-with-
cancer/coping-physically/gvhd/about-graft-versus-host-disease

 Information on bone marrow transplant:

http://www.cancerresearchuk.org/about-cancer/cancers-in-
general/treatment/transplant/bone-marrow-transplants
 References
 Black, J. M., & Hawks, J. H. (2009). Medical-surgical nursing: Clinical
management for positive outcomes (8th ed.). St: Louis: W.B. Saunders.
 Cancer Research UK (2003). Taken from: http://www.cancerresearchuk.org/
 Craven, R. F., Hirnle, C. J., & Jensen, S. (2013). Fundamentals of Nursing:
Human health and function (7th ed.). Philadelphia: Lippincott Williams & Wilkins.
 Fauci, A. S., Braunwald, E., Kasper, D. L., Hauser, S. L., Longo, D. L., Jameson,
J. L., & Loscalzo, J. (2008). Harrison's principles of internal medicine (17th ed.).
New York: McGraw-Hill Medical.
 Hoffbrand, A. V., & Moss, P. A. H. (2011). Essential haematology (6th ed.).
Malden: Blackwell Publishing.
 Jarvis, C. (2012). Physical examination and health assessment. (6th Ed.). St
Louis, MI: Elsevier Saunders.
 Kee, J. (2010). Laboratory and diagnostic tests with nursing implications (8th
ed.). Upper Saddle River: Prentice Hall.
 LeMone, P., & Burke, K. (2008). Medical-surgical nursing: Critical thinking in
client care (4th ed.). New Jersey: Pearson Education, Inc.
 References
 Lewis, S. L., Heitkemper, M., Dirksen, S. R., & O’Brien, P. G. (2010).
Medical-Surgical nursing in Canada: Assessment and management of clinical
problems. (2nd ed.). Toronto: Mosby/Elsevier.
 Porth, C. M., & Matfin, G. (2009). Pathophysiology: Concepts of altered health
states (8th ed.). Philadelphia: Lippincott Williams & Wilkins.
 Smeltzer, S. C., & Bare, B. G. (2010). Brunner & Suddarth’s textbook of
medical-surgical nursing (12th ed.). Philadelphia: Lippincott.