Acute Lymphocytic Leukemia Final

8/6/2019 Acute Lymphocytic Leukemia Final

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s

Acute Lymphocytic

Leukemia


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DefinitionA rapidly progressing form of leukemia that is

characterized by the neoplastic proliferation of the

leukocytes and their precursors.It involves the blood-forming tissues of the bone marrow, spleen and lymphnodes.


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Blood Cell Maturation


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Etiologyy Occurs when a bone marrow cell develop error in its

DNA. This error then tells the cell to continue growing

and dividing causing the bone marrow to continuouslyproduce immature cells that develops into leukemiclymphoblasts. These cells are unable to functionproperly and they can build up and crowd out healthycells.


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Cell Proliferation


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Risk Factorsy Children (most common among men than women

with a peak incidence between 2-5 years of age)

y Exposure to radiation, chemicals/drugs, virusesy Certain genetic disorders (Down Syndrome, Klinefelter

Syndrome)


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Pathophysiologyy C:\Documents and

Settings\Arjay\Desktop\ALL\Pathophysiology of

Acute Lymphocytic Leukemia.doc


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Diagnostic Evaluation1. Blood tests

y A blood test may reveal reduced numbers of

erythrocytes and platelets. Leukocytes may either behigh or low, but there is always a high proportion ofimmature cells.

y Explain the procedure to the patient

y After the procedure, observe for the site for any reaction


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Diagnostic Evaluation2. Bone Marrow test

y A needle is used to remove a sample of bone marrow to

look for leukemia cells. Sample will be classified intospecific cell types based on their size, shape and otherfeatures and to observe for changes in blood cells.

y Check for the signed informed consent

y Help relieve anxiety by explaining the procedure to the patient

y During the actual aspiration, deep breaths may help thepatient relieve pain felt

y After the procedure, patient will be on lying position and isobserved for bleeding for one hour

y Monitor patients vital signs after the procedure


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Diagnostic Evaluation3. Imaging Test (CT scan)

y It helps determine whether cancer has spread to other

parts of the body.y Remove any metal objects

y Check for informed consent if contrast agent will be used

y If with contrast agent, check for patients allergies

y Assess for phobia to enclosed spaces or claustrophobia

y Help relieve patients anxiety by explaining the procedure


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Drug AnalysisyALL Report\drugs final(all).doc


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Nursing Managementy Provide comfort to the patient.

y Have a clean and neat environment.

y Explain that chemotherapy may cause weight loss andhair loss.

y Encourage the patient to eat a diet high calories andprotein.


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Nursing Managementy If patient have a oral lesions, teach the patient to use

soft tooth brush or cloth, and to avoid hot, spicy foods,

and commercial mouthwashes, which can irritatesmouth ulcers.

y Encourage the patient to take frequent rest periodsduring the day and to space activities with rest.

y

Encourage to drink atleast 2000ml of fluids per day.


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Nursing Managementy Preventing infection:

y Monitor for fever, f lushed appearance, chills,

tachycardia; appearance of white patches in the mouth,cough, abdominal pain, skin rash.

y Avoid invasive procedures and trauma to skin or mucousmembrane to prevent entry of microorganisms.

y Use the following rectal precautions to preventinfections: Avoid diarrhea and constipation, which canirritate the rectal mucosa, avoid the use of rectalthermometers, and keep perineal are clean.


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Nursing Managementy Care for the patient in private room with strict

handwashing practice.

y

Encourage and assist patient with personal hygiene,bathing, and oral care.

y Obtain cultures and administer antimicrobials promptlyas directed.


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Nursing Managementy Preventing and Managing bleeding:

y Watch for signs of minor bleeding, such as petechiae,

ecchymosis, conjunctival hemorrhage, epistaxis,bleeding gums, bleeding at puncture sites, vaginalspotting, heavy menses.

y Test all urine, stool, emesis for gross and occult blood.

y Monitor platelet counts daily.

y Administer blood components as directed.

y Keep patient on bed rest during bleeding episodes.


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Nursing Managementy Patient Education and Health Maintenance:

y Teach signs and symptoms of infection and advise whom

to notify.y Encourage adequate nutrition to prevent emaciation

from chemotherapy.

y Teach avoidance of constipation with increased f luidand fiber, and good perineal care.

y Encourage regular dental visits to detect and treat dentalinfections and disease.


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Medical- Surgical Management1. Chemotherapy

y This is the treatment choice of most types of leukemia,

with a goal of eradicating leukemic cells andproducing remission. Children with this disease arelikely to be cured and a number of adult patients havehigh remissions.


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Medical- Surgical Management

y Chemotherapy treatment can be divided into four

phases:y First phase induction chemotherapy

y Second phase consolidation chemotherapy

y Third phase maintenance chemotherapy

y Fourth phase central nervous system (CNS)prophylaxis


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Medical- Surgical Management

a. Induction Chemotherapy

y The induction chemotherapy is done in the hospital andmost patients need to be in the hospital forapproximately four weeks.

y Most common drugs used in the treatment of ALL are:

y

Daunorubin (cerubidine, an antitumor antibiotic)y Vincristine (oncovin, a plant alkaloid)

y Prednisone

y Asparaginase (elspar).


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Medical- Surgical Managementy Induction treatment for ALL is somewhat more gentle than

that for AML.

y Intensive supportive care is still needed including transfusion

of red blood cells and platelets.y Although the likelihood of mouth sores and disruption of the

intestinal tract is rare, complete but temporary hair loss doesoccur.

y Once blood counts have returned to normal, a repeat bone

marrow biopsy is performed to determine whether the patienthas entered complete remission.

y A complete remission is achieved when the blood and bonemarrow show no evidence of persistent leukemia and bloodcounts have returned to normal.


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Medical- Surgical Managementb. Consolidation Chemotherapy

y Includes multiple cycles of intensive chemotherapygiven over a six- to nine-month period.

y Frequent hospitalizations are required and intensivesupportive care is still needed, including red blood celland platelet transfusions.

y Stem cell transplantation is not typically performed to

treat ALL unless abnormal cytogenetics are present.y Chemotherapy agents used during consolidation include

the same agents used during induction, as well as Ara-C,etoposide, methotrexate and 6-mercaptopurine.


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Medical- Surgical Managementc. Maintenance Chemotherapy

y Once patients have completed intensive chemotherapy,they need to take oral chemotherapy pills for anadditional 18 to 24 months.

y These oral chemotherapy pills typically methotrexateand 6-mercaptopurine are usually well-tolerated withonly minimal side effects.

y Patients need to have their blood tests checked once amonth while taking chemotherapy pills.

y Most patients with ALL can return to work duringmaintenance therapy.


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Medical- Surgical Managementd. Central Nervous System (CNS) Prophylaxis

y ALL frequently can recur in the spinal fluid, the fluid

that bathes the spinal column and brain. To preventrelapse at this location, chemotherapy must be injecteddirectly into the fluid that bathes the spinal column.

y This is done by inserting a needle between the vertebraeof the lower back called a spinal tap or lumbar

puncture and infusing chemotherapy directly into theclear spinal fluid. This is called intrathecalchemotherapy.


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Medical- Surgical Managementy Patients are routinely given six or more injections of

intrathecal chemotherapy to prevent recurrence of ALL.

y

More injections may be necessary if leukemia cells aredetected in the spinal fluid.

y Most people complete intrathecal therapy within two tofour months of starting their treatment.

y Headaches and nausea are occasional side effects.


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Medical- Surgical Management2. Radiation Therapy (Radiotherapy)

y Uses high-energy rays to kill leukemia cells.

Radiotherapy damages cellular DNA. Though theleukemic cells continue to function, it cannot divide andmultiply

y Radiotherapy is also aimed at the spleen, the brain, orother parts of the body where leukemia cells have

collected.


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Medical- Surgical Management3. Bone Marrow Transplant (BMT)

y This is often used in conjunction with chemotherapy or

radiation. There are 2 categories:a.Allogenic BMT

y Uses the bone marrow of a healthy donor (usually from asibling/unrelated closed matched antigen. The donors

bone marrow is aspirated and is infused through acentral venous line into the recipient.


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Medical- Surgical Managementb.Autologous BMT (orbone marrow rescue)

y Uses the client own bone marrow to restore the bonemarrow function after chemotherapy or radiation. During

the period of disease remission, about 1L of bone marrow isaspirated from the patient. It is then stored and frozen foruse after treatment of chemotherapy or radiation, with theaim of destroying the immune system and malignant cellsand to prepare space in the bone marrow for new cells. The

filtered bone marrow is thawed and infused intravenouslythrough central line and slowly become part of the clientsbone marrow, neutrophil count increases, and normalhaematopoiesis takes place.


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Medical- Surgical Management4.Allogeneic Stem Cell Transplant

y Is a replacement of the recipients blood cell lines

(WBCs, RBCs, and platelets) with cells derived from thedonor stem cells. This is an alternative to bone marrowtransplant. The recipient and the donor tissue must beclosely matched prior to harvesting and necessaryprocedure and treatment are conducted prior to

harvesting to prevent the risk of infection and othercomplications.


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Nursing Care PlanyALL\NCP.doc