What is Leukemia?

Leukemia is defined as a general term referring to a specific group of malignant disorders. These 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 can start in other blood cell types. There are several types of leukemia, which branch off based on whether the leukemia is acute or chronic, and on whether it begins to form in myeloid cells or lymphoid cells.

Different types of leukemia have different prognoses and treatment options. The disease process of leukemia involves a loss of regulation in cell division due to 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 this disease. Although many people believe that leukemia is most commonly diagnosed in children, this disease affects approximately nine times more adults than it does children. It poses a higher risk for males than for females and affects those of European descent more than African, Alaskan, and American Indians.

Most cancers, including leukemia, are caused by mutations in the DNA of specific cells. Both genetic and environmental factors are considered causes of the majority of leukemia types. Oncogenes, or abnormal genes, can cause leukemia. The disease's development has also been correlated with exposure to chemical agents, chemotherapeutic agents, radiation, untreated viruses, and deficiencies in the immune system. Leukemia is classified based on whether the disease is acute or chronic. The terminology acute and chronic refer to the nature of disease onset and the maturity of the affected cell.

Acute leukemia involves the clonal proliferation of immature hematopoietic cells. Leukemia develops after the malignant transformation of an immature hematopoietic cell, followed by cellular replication and the subsequent expansion of that same malignant clone. If the disease onset is gradual and the white blood cell (WBC) is mature, chronic leukemia can be diagnosed. Finally, 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 are identified by combining the acute and chronic categories with the type of cell involved. These types are Acute Myelogenous Leukemia (AML), Acute Lymphocytic Leukemia (ALL), Chronic Myelogenous Leukemia (CML), and Chronic Lymphocytic Leukemia (CLL).

Acute myelogenous leukemia constitutes only one fourth of all the different types of leukemia. However, it represents 80% of the acute leukemias in adults. It's characterized by dramatic and abrupt onset and the uncontrolled proliferation of myoblasts. The clinical manifestations are related to the replacement of hematopoietic cells in the bone 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. Arising from B-cell origin, the bone marrow is proliferated with immature lymphocytes. The clinical manifestations of ALL include leukemic meningitis caused by arachnoid infiltration and serious central nervous system dysfunctions.

The onset of the disease is characterized by fever, bleeding, and progressive weakness. Chronic myelogenous leukemia is caused by the overdevelopment of mature neoplastic granulocytes in the bone marrow. CML has a chronic stable phase that can last years, followed by a very acute and aggressive phase called the blastic phase. The blastic phase eventually transforms into an accelerated acute phase and then requires treatment akin to acute leukemia—swiftly 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, which then causes pulmonary symptoms. Most adults in the early stages of CLL require no treatment, but others need to be closely monitored for the progression and aggression of the disease.

Leukemia treatment brings forth a variety of complex ethical and moral dilemmas, which include setting limits on clinical medical intervention, managing 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. Anticipating and mitigating potential dilemmas and having a multidisciplinary team possessing the required domain expertise to help manage patient concerns can lead to improved patient care." (Ethical Issues in Patients with Leukemia: Practice Points and Educational Topics for the Clinical Oncologist and Trainees). Health-care providers, including doctors and nurses, must establish a rapport and enact open communication to help achieve reasonable goals aligned with the patient's views and values.

Bone marrow examination and peripheral blood evaluation are the main mechanisms of action for diagnosing and characterizing types of leukemia. CT scans and lumbar punctures are other studies that may be used. When a nurse is providing care for a patient with leukemia, both subjective and objective data are very important to obtain. The patient should provide 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 also be noted. When assessing the integumentary system, pallor or jaundice, ecchymosis, macules, and papules may be present. Cardiovascular abnormalities, such as tachycardia and systolic murmurs, are also expected to be present. Other symptoms like gingival bleeding, oral ulcerations, Candida infection, and hyperplasia may be present. Upon palpation, splenomegaly can be detected as well. Leukemia patients typically exhibit an elevated white blood cell count with a shift to the left, decreased hematocrit and hemoglobin levels, thrombocytopenia, and a hypercellular bone marrow aspirate.

The nursing diagnosis as it relates to the care of a patient with or newly diagnosed with leukemia can vary. Prior to a treatment plan being established, and after the diagnosis of leukemia has been given, many psychosocial nursing diagnoses will apply. These diagnoses include fear and/or anxiety related to the diagnosis of leukemia, ineffective health management related to a lack of knowledge about appropriate nutrition and medication regimen, and decisional conflict related to a lack of knowledge about treatment options and their effects. The priority nursing diagnosis of a patient with leukemia is the risk of infection related to immunosuppression and alterations in mature white blood cells. The risk for bleeding due to a decreased platelet count (thrombocytopenia), fatigue related to inadequate oxygenation of the blood, and impaired oral mucous membrane related to low platelet counts and/or the effects of pathological conditions and treatments are all examples of physiological nursing diagnoses.

The initial goal after a patient has been diagnosed with leukemia is to attain remission. Chemotherapy is the main treatment method for 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 the WBC count and the risk of leukemia cell-induced thrombosis." (Elsevier, 2017) Chemotherapy is divided into three stages: induction therapy, post-induction or post-remission therapy, and maintenance. When providing treatment for a patient with leukemia, it is imperative that the nurse understands the specific type of leukemia the 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 is in assessment. The nurse should monitor for complications of chemotherapy affecting the gastrointestinal system, skin mucosa, nutritional status, kidneys, liver, neurologic system, and cardiopulmonary status. They must closely monitor the temperature and note any correlation between temperature elevations and chemotherapy treatments. They should also observe for fever associated with tachycardia, hypotension, and subtle mental changes." (Vera, 2014). The nurse should pay close attention to the drugs being administered, mindful of 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 expected. Consequently, nurses should teach the caregiver and patient about the importance of continued disease management and attending follow-up appointments.

Informing the patient about self-care measures and when to contact their healthcare provider about suspicious disease progression are two other important nursing responsibilities when caring for leukemia patients. Most patients should receive an annual influenza vaccination and pneumococcal vaccine. Nurses should also ensure that patients are kept in private rooms and limit visitors to prevent the transmission of pathogens and germs. Due to extreme immunosuppression, live flowers and plants should be disallowed, and all fresh fruits should be properly washed and peeled. Strict hand-washing procedures should be adhered to by anyone coming into contact with patients to prevent the risk of infection and cross-contamination. Last but not least, charge nurses should coordinate care to prevent these patients from coming into contact with staff and other nurses who render care for other patients with infectious diseases or any infection at all.

Treatment results and outcomes will vary amongst leukemia patients, partly because there are different types of leukemia. However, advances in treatment therapies, stem cell transplantation, better supportive care, and drug research have all contributed to improving outcomes and quality of life for those diagnosed with blood cancers such as leukemia. The expected outcomes for leukemia treatment primarily involve disease management and functionality restoration for the patient. A decrease in the number and maturation of white blood cells is an expected result of leukemia treatment. Ideally, patients should experience no complications related to the 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 primary treatment for a leukemic patient is chemotherapy, during which, the nurse plays a crucial role in educating and managing the disease. The nurse must ensure the prevention of germ spread and decrease the risk of infection as the patient is highly immunosuppressed. Expected outcomes include the patient having a comprehensive understanding of the disease, its management, and overall restoration of functional ability. Receiving a diagnosis of any cancer type, especially blood cancer, may seem scary and almost impossible to defeat. However, with the dedication of nurses and adherence to treatment from patients, becoming a functional member of society and leading a full life is more than an achievable goal.

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