What is Leukemia?

Leukemia is defined as the general term to refer to a specific group of malignant disorders. These malignant disorders affect the blood and blood-forming tissues of the lymph system, bone marrow, and spleen. Most often, leukemia is a cancer of the white blood cells, but some specific types of leukemia start in other blood cell types. There are several types of leukemia. The types of leukemia are branched off based on if the leukemia is acute or chronic, and whether or not it begins to form in myeloid cells or lymphoid cells. Different types of leukemia have different prognosis and treatment options. Leukemia has a disease process that involves the loss of regulation in cell division because of an over-accumulation of dysfunctional cells. Each year, an estimated 52,380 new cases are diagnosed. “Approximately 1.5 percent of men and women will be diagnosed with leukemia at some point during their lifetime, based on 2013-2015 data.” (cancer.gov) An estimated 405,815 people in the United States were living with leukemia in 2015 and an overall 63.7 percent of adults survive with the disease. Many people believe that leukemia is most commonly diagnosed in the childhood years, but this disease affects approximately nine times more adults than it does children. It has a higher risk to affect males than females and affect those of European descent than African, Alaskan, and American Indians.

It is known that most cancers, including leukemia, are caused by a mutation in the DNA of specific cells. A combination of genetic and environmental factors are said to cause the majority of the types of leukemia. Oncogenes, which are abnormal genes, are capable of causing leukemia. The development of this disease has also been correlated with coming into contact with chemical agents, chemotherapeutic agents, radiation, leaving viruses untreated, and deficiencies of the immune system. Leukemia is classified based on if the disease is acute or chronic. Acute and chronic refer to the nature of disease onset and how mature the effected cell is.

Acute leukemia involves the clonal proliferation of immature hematopoietic cells. After malignant transformation of an immature hematopoietic cell, followed by cellular replication and lastly expansion of that same malignant clone, leukemia is developed. When disease onset is gradual and the WBC is mature, chronic leukemia can be diagnosed. Lastly, leukemia can be characterized by identifying the type of leukocyte involved. The cell can be of lymphocytic or myelogenous origin. The four major types of leukemia can be identified by combining the acute and chronic categories with the type of cell involved. Acute myelogenous leukemia (AML), acute lymphocytic leukemia (ALL), chronic myelogenous leukemia (CML), and chronic lymphocytic leukemia (CLL) are the types of this disease.

Acute myelogenous leukemia makes up only one-fourth of all the different types of leukemia, but 80% of it represents for the acute leukemias in adults. It has a dramatic and abrupt onset and is characterized by the uncontrolled proliferation of myoblasts. Clinical manifestations are related to the replacement of hematopoietic cells in the blood marrow, by leukemic myoblasts. Acute lymphocytic leukemia accounts for 20% of acute leukemias in adults and is the most common form of leukemia in children. It is of the ??- cell origin and the bone marrow is proliferated with immature lymphocytes. Clinical manifestations of ALL include leukemic meningitis caused by arachnoid infiltration and serious central nervous systems dysfunctions.

The onset of the disease is characterized by fever, bleeding, and progressive weakness. Chronic myelogenous is caused by the over the development of mature neoplastic granulocytes in the bone marrow. CML has a chronic stable phase that can last years followed by a very acute, aggressive phase called, the blastic phase. Next, the blastic phase will transform into the accelerated acute phase and then it must be treated like it is a form of acute leukemia, very quickly, and aggressively. The most common leukemia in adults is chronic lymphocytic leukemia. It is characterized by the accumulation and production of functionally inactive mature lymphocytes. Lymph node enlargement is present due to the lymphocytes infiltrating the bone marrow and then causes pulmonary symptoms. Most adults in the early stages of CLL require no treatment, but others need to be followed closely to monitor the progression and aggression of the disease.

Treating leukemia comes with a variety of complex ethical and moral dilemmas including the limits of clinical medical intervention, managing the patient’s expectations, meeting the patient’s goals, and coping with suffering. “Insight into the most common types of ethical issues provides a substrate to build a foundation for continued development in ethical clinical practice. Knowing to anticipate and mitigate potential dilemmas and having a multidisciplinary team with the specific domain expertise to assist in managing patient concerns will translate into improved patient care.” (Ethical Issues in Patients with Leukemia: Practice Points and Educational Topics for the Clinical Oncologist and Trainees) Health care providers and nurses must establish rapport, trust, and ensure that open communication is being used to achieve reasonable goals and that align with the patient’s views and values.

Bone marrow examination and peripheral blood evaluation are the main mechanisms of action of diagnosing and characterizing types of leukemia. CT scan and lumbar puncture are other studies that may be used. A nurse who is providing care for a patient with leukemia, both subjective and objective data are very important to obtain. The patient should give a thorough past health history including exposure to any chemical toxins such as benzene and arsenic. Exposure to radiation and the Epstein- Barr virus should be noted as well. When assessing the integumentary system, pallor or jaundice, ecchymosis, macules, and papules may be present. When assessing for cardiovascular abnormalities, tachycardia, and systolic murmurs are expected to be present. Gingival bleeding, oral ulcerations, Candida infection, and hyperplasia are present. Upon palpation, splenomegaly can be detected as well. An elevated white blood cell count with a shift to the left is also present in leukemia patients. Decreased hematocrit and hemoglobin levels, thrombocytopenia, and hypercellular bone marrow aspirate are also present.

Nursing diagnosis as it relates to the care of a patient with or newly diagnosed with leukemia can vary. Prior to a plan of treatment, and after the diagnosis of leukemia has been given, many psychosocial nursing diagnoses will apply. Fear and/or anxiety related to the diagnosis of leukemia, Ineffective health management related to lack of knowledge about appropriate nutrition and medication regimen, and Decisional Conflict related to lack of knowledge about treatment options and their effects, all are examples of psychosocial nursing diagnosis related to leukemia. The priority nursing diagnosis of a patient with leukemia is Risk for infection related to immunosuppression and alterations in mature white blood cells. The risk for bleeding related to decreased platelet count (thrombocytopenia), Fatigue related to inadequate oxygenation of the blood, and Impaired oral mucus membrane related to low platelet counts and/or effects of pathologic conditions and treatments are all examples of physiological nursing diagnosis.

The initial goal after a patient has obtained a medical diagnosis of leukemia is attaining remission. Chemotherapy is the main treatment of leukemia. “With leukemia, the white blood cell count is extremely high (100,000 cells/?µL or more) and initial emergent treatment may include leukapheresis and hydroxyurea. The purpose of these treatments is to reduce WBC count and risk of leukemia cell-induced thrombosis.” (Elsevier, 2017) Chemotherapy is divided into three stages: induction therapy, post-induction or post-remission therapy, and maintenance. In providing treatment for a patient with leukemia, it is imperative that the nurse understand the specific type of leukemia that patient has. “Patients may have comorbid conditions that affect treatment decisions.

Important nursing interventions include maximizing the patient’s physical functioning, teaching patients that acute side effects of treatment are usually temporary, and encouraging patients to discuss their quality- of- life issues.” (Elsevier, 2017) During chemotherapy, a nurse’s most important role in the assessment. The nurse should monitor for complications of chemotherapy that affect the gastrointestinal system, skin mucosa, nutritional status, kidneys, liver, neurologic system, and cardiopulmonary status. Closely monitor the temperature. “The nurse must note a correlation between temperature elevations and chemotherapy treatments. Observe for fever associated with tachycardia, hypotension, and subtle mental changes.” (Vera, 2014) The nurse should pay close attention to drugs that are being administered, including the drug’s purpose, mechanism of action, routes of administration, and toxic effects. For a patient requiring maintenance or long term therapy, extreme fatigue is an expected side effect, therefore nurses should teach the caregiver and patient the importance of continued disease management and attending follow up appointments.

Informing the patient about self- care measures and when to contact their health care provider about suspicious disease progression are two of the most important nursing implementations and roles in providing care of a patient with leukemia. Most patients should receive an annual influenza vaccination and pneumococcal vaccine. The nurse should also place the patient in a private room, and limit visitors to prevent transmission of pathogens and germs. Due to extreme immunosuppression, live flowers and plants should be prohibited and fresh fruits need to be properly washed and peeled. Enforce strict handwashing procedures for all that come into contact with the patient to prevent the risk of infection and cross-contamination. Lastly, the charge nurse should coordinate patient care so that leukemic patient does not come in contact with staff and other nurses who render care for patients with infectious diseases or any infection at all.

Treatment results and outcomes will vary among leukemia patients, partially based on the fact that there are different types of leukemia. Newer treatment therapies, progress in stem cell transplantation, better supportive care, and studies of new drugs have all contributed to improving outcomes and quality of life for people diagnosed and living with blood cancers such as leukemia. The expected outcomes of treatment of leukemia mainly involve, management of the disease and being able to restore the functional ability of the patient. A decrease in the number and maturation of white blood cells are an expected outcome of leukemia treatment. The patient should experience no complications related to treatment or disease.

Leukemia is a malignant blood disorder of the blood and its forming tissues. There are four types of leukemia: Acute myelogenous leukemia (AML), acute lymphocytic leukemia (ALL), chronic myelogenous leukemia (CML), and chronic lymphocytic leukemia (CLL). The specific type of leukemia is characterized by identifying the type of leukocyte involved. The cell can be of myelogenous or lymphocytic origin. The main treatment of a leukemic patient is chemotherapy, and with that, the nurse plays a great role in the education and management of the disease. The nurse must ensure the prevention of the spread of microorganisms and outside germs and decrease the risk of infection due to the patient being extremely immunosuppressed. Expected outcomes include the patient having a complete understanding of the disease, management of the disease, and overall restoration of functional ability. Although being diagnosed with any type of cancer, and especially cancer of the blood seems scary and almost impossible to defeat, but with the hard work of nurses, and patients adherent to treatment, being a functional member of society and living a full life is more than an obtainable goal.

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