Introduction
Leukemia is a cancer of the blood-forming tissues, including the bone marrow and the lymphatic system.
Many types of leukemia exist. Some forms of leukemia are more common in children. Other forms of leukemia occur mostly in adults.
Leukemia usually involves white blood cells. The WBC are potent infection fighters – they normally grow and divide in an orderly way, as the body needs them. But in people with leukemia, the bone marrow produces an excessive amount of abnormal WBC, which don’t function properly.
Treatment for leukemia can be complex — depending on the type of leukemia and other factors. But there are strategies and resources that can help make your treatment successful.
Some types of leukemia are more commonly found in children, while other forms are usually seen in adults. Currently, there is no absolute cure for leukemia.
However, the treatment plans for leukemia have been rapidly developed in the past few decades. These have shown promising results in terms of the overall increase in survivorship and improvement of the quality of life for patients.
This blog post discusses what leukemia is, its symptoms nursing care plans and interventions with some examples .As you follow along, remember that our qualified writers are always ready to help in any of your nursing assignments. All you need to do is place an order with us!
Disclaimer: The information presented in this article is not medical advice; it is meant to act as a quick guide to nursing students for learning purposes only and should not be applied without an approved physician’s consent. Please consult a registered doctor in case you’re looking for medical advice.
Signs and Symptoms of Leukemia
Each type of leukemia may have varying signs and symptoms. Generally, leukemia patients have the following clinical manifestations:
- Fever or chills
- Bone pain or tenderness
- Swollen lymph nodes, enlarged liver or spleen
- Persistent fatigue
- Myalgia
- Malaise or generalized body weakness
- Moderate to severe infections, which may be recurrent
- Unexplained or unintentional weight loss
- Recurrent nosebleeds
- Tendency to bleed or bruise easily
- Petechiae – tiny red spots on the skin
- Excessive sweating, especially at night (nocturnal hyperhidrosis)
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Types of Leukemia
Based on Progression:
Acute leukemia – this condition occurs when the young and immature white blood cells called blasts rapidly multiply and are unable to perform according to their normal functions. The symptoms worsen quickly, requiring the patient to commence an aggressive treatment as early as possible.
Chronic leukemia – this condition happens when more mature blood cells either slowly replicate or accumulate. It may involve either an increased or decreased production of these abnormal blood cells. They may also be able to function normally in the beginning. Thus the symptoms may not appear until years later.
Based on the Affected White Blood Cell Type:
- Lymphocytic leukemia – this condition involves the lymphocytes, which are the immune cells formed in the lymphatic tissue.
- Acute lymphocytic leukemia (ALL) – is common in children but can also be found in some adults.
- Chronic lymphocytic leukemia (CLL) – common in adults who may be well and asymptomatic for years
- Myelogenous leukemia – this condition affects the myeloid cells, which are the precursors of leukocytes (white blood cells), erythrocytes (red blood cells), and thrombocytes (platelets)
- Acute myelogenous leukemia (AML) – occurs more commonly in adults but can also be diagnosed in children.
- Chronic myelogenous leukemia (CML) – occurs more commonly in adults who may be well and asymptomatic for years but will experience rapid growth and replication of leukemia cells.
Rare Types:
There are several rare types of leukemia which include:
Hairy cell leukemia – slow progressive cancer that involves the excessive production of B cells / B lymphocytes
Myelodysplastic syndromes (MDS) – a group of leukemia disorders wherein the blood-forming cells produced in the bone marrow undergo dysplastic change accompanied by ineffective hematopoiesis (the process of forming blood cellular components)
Myeloproliferative disorders (MPD) – a group of leukemia disorders that involve the abnormal growth or proliferation of the blood cells in the bone marrow accompanied by effective hematopoiesis
Causes and Risk Factors of Leukemia
Currently, the exact cause of leukemia is unknown. As with other types of cancer, leukemia is believed to develop from various factors in both a person’s genetic makeup and his or her environment.
The combination of these factors causes changes called mutations in the genetic material (DNA) of the blood cells, causing them to grow and divide immaturely and rapidly.
These abnormal blood cells crown the bone marrow, which leads to the decreased production of healthy blood cells.
Risk Factors for Leukemia
- Family history of leukemia
- Previous cancer treatment such as chemotherapy or radiotherapy
- Genetic disorders such as Down syndrome
- Smoking
- Chemical exposure – this may include chemicals like benzene in gasoline.
Complications of Leukemia
Leukemia may cause several complications, which may include::
- Recurrent infections due to low levels of immunity
- Unintentional weight loss
- Anemia
- Bleeding problems
- Metabolic abnormalities – may lead to organ failure, particularly in the kidneys.
- Central nervous system impairment
- Cataracts
- Infertility
- Increased risk of other types of cancer
- Mental health problems
- Poor quality of life
Diagnosis of Leukemia
History taking – to check for family history of leukemia and cancers, smoking history, and other risk factors.
Physical exam – to assess the body for the clinical manifestations of leukemia, especially swollen lymph nodes, enlargement of liver and spleen, and presence of fever and chills
Blood tests – include complete and differential blood counts
Bone marrow biopsy – to look for leukemia cells by means of taking a sample of bone marrow from the patient’s hipbone using a long, thin needle; also called bone marrow aspiration
Lumbar puncture – to check for the presence of leukemia cells in the cerebrospinal fluid if the bone marrow biopsy is positive for leukemia; also called spinal tap
Treatment for Leukemia
- Medications. Several pharmacologic therapies have been used to treat leukemia, such as:
- Chemotherapy – uses drugs to kill cancer cells. The most common chemotherapy protocols for leukemia may include combinations of anti-tumor antibiotics, vinca alkaloids, and other systemic anti-cancer therapy (SACT) medications.
- Targeted Therapy – uses drugs that attack specific abnormalities in the cancer cell.
- Immunotherapy – utilizes the immune system to attack the leukemia cells; examples include immune system modulators and checkpoint inhibitors.
2. Radiotherapy. Radiotherapy uses radiation or high-powered energy beams such as protons and X-rays to kill cancer cells. This can last from 3 days to 6 weeks.
- External beam radiation – aims the energy beams at the affected body area
- Brachytherapy – places radioactive material inside the body in order to perform radiation therapy
3. Chimeric antigen receptor (CAR)-T Cell Therapy. This is a specialized treatment that involves the harvesting of the patient’s T-cells, engineering them to fight the leukemia cells, and infusing them back into the patient’s body.
4. Bone Marrow Transplant. BMT is a procedure wherein the unhealthy bone marrow of the leukemia patient is removed and replaced by healthy stem cells, which will cause regeneration of healthy bone marrow to produce normal blood cells. It is also known as stem cell transplant.
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Nursing Care Plans for Leukemia Based on Diagnosis
Nursing Care Plan 1: Diagnosis – Risk for Infection
Risk factors may include:
- Inadequate secondary defenses: alterations in mature WBCs (low granulocyte and abnormal lymphocyte count), increased number of immature lymphocytes; immunosuppression, bone marrow suppression (effects of therapy/transplant)
- Inadequate primary defenses (stasis of body fluids, traumatized tissue)
- Invasive procedures
- Malnutrition; chronic disease
Desired Outcome
Patient will:
- Identify actions to prevent/reduce the risk of infection.
- Demonstrate techniques lifestyle changes to promote a safe environment achieve timely healing.
Nursing Interventions
Infection Protection
Independent
Place in a private room. Screen/limit visitors as indicated. Prohibit the use of live plants/cut flowers. Restrict fresh fruits and vegetables or make sure they are washed or peeled.
Rationale: Protect the patient from potential sources of pathogens/infection. Note: Profound bone marrow suppression, neutropenia, and chemotherapy place patient at great risk for infection.
Require good handwashing protocol for all personnel and visitors.
Rationale: Prevents cross-contamination/reduces the risk of infection.
Monitor temperature. Note the correlation between temperature elevations and chemotherapy treatments. Observe for fever associated with tachycardia, hypotension, subtle mental changes.
Rationale: Although fever may accompany some forms of chemotherapy, progressive hyperthermia occurs in some types of infections, and fever (unrelated to drugs or blood products) occurs in most leukemia patients. Note: Septicemia may occur without fever.
Prevent chilling. Force fluids, administer tepid sponge bath.
Rationale: Helps reduce fever, which contributes to fluid imbalance, discomfort, and CNS complications.
Encourage frequent turning and deep breathing.
Rationale: Prevents stasis of respiratory secretions, reducing the risk of atelectasis/pneumonia.
Auscultate breath sounds, noting crackles rhonchi; inspect secretions for changes in characteristics, e.g., increased sputum production or change in sputum color. Observe urine for signs of infection, e.g., cloudy, foul-smelling, presence of urgency, or burning with voids.
Rationale: Early intervention is essential to prevent sepsis/septicemia in an immunosuppressed person.
Handle the patient gently. Keep linens dry/wrinkle-free.
Rationale: Prevents sheet burn/skin excoriation.
Inspect the skin for tender, erythematous areas; open wounds. Cleanse skin with antibacterial solutions.
Rationale: May indicate local infection. Note: Open wounds may not produce pus because of an insufficient number of granulocytes.
Inspect oral mucous membranes. Provide good oral hygiene. Use a soft toothbrush, sponge, or swabs for frequent mouth care.
Rationale: The oral cavity is an excellent medium for the growth of organisms and is susceptible to ulceration and bleeding.
Promote good perianal hygiene. Examine the perianal area at least daily during acute illness. Provide sitz baths, using Betadine or Hibiclens if indicated. Avoid rectal temperatures using suppositories.
Rationale: Promotes cleanliness, reducing the risk of perianal abscess; enhances circulation and healing. Note: Perianal abscess can contribute to septicemia and death in immunosuppressed patients.
Coordinate procedures and tests to allow for uninterrupted rest periods.
Rationale: Conserves energy for healing cellular regeneration.
Encourage increased intake of foods high in protein and fluids with adequate fiber.
Rationale: Promotes healing and prevents dehydration. Note: Constipation potentiates retention of toxins and the risk of rectal irritation/tissue injury.
Avoid/limit invasive procedures (e.g., venipuncture and injections) as possible.
Rationale: Break in the skin could provide an entry for pathogenic/potentially lethal organisms. The use of central venous lines (e.g., tunneled catheter or implanted port) can effectively reduce the need for frequent invasive procedures and the risk of infection. Note: Myelosuppression may be cumulative in nature, especially when multiple drug therapy (including steroids) is prescribed.
Collaborative
Monitor laboratory studies, e.g., CBC, noting whether WBC count falls or sudden changes occur in neutrophils.
Rationale: Decreased numbers of normal/mature WBCs can result from the disease process or chemotherapy, compromising the immune response and increased risk of infection.
Gram’s stain cultures/sensitivity.
Rationale: Verifies presence of infections; identifies specific organisms and appropriate therapy.
Review serial chest x-rays.
Rationale: Indicator of development/resolution of respiratory complications.
Prepare for/assist with leukemia-specific treatments such as chemotherapy, radiation, and/or bone marrow transplant.
Rationale: Leukemia is usually treated with a combination of these agents, each requiring specific safety precautions for patients and care providers.
Administer medications as indicated, e.g., antibiotics.
Rationale: May be given prophylactically or to treat a specific infection.
Colony-stimulating factors: sargramostim (Leukine).
Rationale: Restores WBCs destroyed by chemotherapy and reduces the risk of severe infection and death in certain types of leukemia.
Avoid use of aspirin-containing antipyretics.
Rationale: Aspirin can cause gastric bleeding and further decrease platelet count.
Provide a nutritious diet high in protein and calories, avoiding raw fruits, vegetables, or uncooked meats.
Rationale: Proper nutrition enhances the immune system. Minimizes potential sources of bacterial contamination.
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Nursing Care Plan 2: Diagnosis – Fluid Volume and Risk for Deficient
Risk factors may include:
- Excessive losses, e.g., vomiting, hemorrhage, diarrhea
- Decreased fluid intake, e.g., nausea, anorexia
- Increased fluid need, e.g., hypermetabolic state, fever; predisposition for kidney stone formation/tumor lysis syndrome
Desired outcomes
Patient will:
- Demonstrate adequate fluid volume, as evidenced by stable vital signs, palpable pulses, urine output, specific gravity, and pH within normal limits.
- Identify individual risk factors and appropriate interventions.
- Initiate behaviors/lifestyle changes to prevent the development of dehydration.
Nursing Intervention
Fluid Management
Independent
Monitor I&O. Calculate insensible losses and fluid balance. Note decreased urine output in the presence of adequate intake. Measure specific gravity and urine pH.
Rationale: Tumor lysis syndrome occurs when destroyed cancer cells release toxic levels of potassium, phosphorus, and uric acid. Elevated phosphorus and uric acid levels can cause crystal formation in the renal tubules, impairing filtration and leading to renal failure.
Weigh daily.
Rationale: Measure of the adequacy of fluid replacement and kidney function. Continued intake greater than output may indicate renal insult/obstruction.
Monitor BP and HR.
Rationale: Changes may reflect the effects of hypovolemia (bleeding/dehydration).
Evaluate skin turgor, capillary refill, and general condition of mucous membranes.
Rationale: Indirect indicators of fluid status/hydration.
Note the presence of nausea fever.
Rationale: Affects intake, fluid needs, and route of replacement.
Encourage fluids of up to 3–4 L/day when oral intake is resumed.
Rationale: Promotes urine flow, prevents uric acid precipitation and enhances clearance of antineoplastic drugs.
Bleeding Precautions
Independent
Inspect skin/mucous membranes for petechiae ecchymotic areas; note bleeding gums, frank or occult blood in stools and urine; oozing from invasive-line sites.
Rationale: Suppression of bone marrow and platelet production places the patient at risk for spontaneous/uncontrolled bleeding.
Implement measures to prevent tissue injury/bleeding, e.g., gentle brushing of teeth or gums with a soft toothbrush, cotton swab, or sponge-tipped applicator; using an electric razor and avoiding sharp razors when shaving; avoiding forceful nose blowing and needlesticks when possible; using sustained pressure (sandbags or pressure dressings) on oozing puncture/IV sites.
Rationale: Fragile tissues and altered clotting mechanisms increase the risk of hemorrhage following even minor trauma.
Limit oral care to mouthwash if indicated (a mixture of 1/4 tsp baking soda or salt in 4–8 oz water or hydrogen peroxide in water). Avoid mouthwashes with alcohol.
Rationale: When bleeding is present, even gentle brushing may cause more tissue damage. Alcohol has a drying effect and may be painful to irritated tissues.
Provide a soft diet.
Rationale: May help reduce gum irritation.
Fluid Management
Collaborative
Administer IV fluids as indicated.
Rationale: Maintains fluid/electrolyte balance in the absence of oral intake; prevents or minimizes tumor lysis syndrome; reduces the risk of renal complications.
Administer medications as indicated, e.g., Antiemetics: 5-HT3 receptor antagonist drugs such as ondansetron (Zofran) or granisetron (Kytril)
Rationale: Relieves nausea/vomiting associated with administration of chemotherapy agents.
Allopurinol (Zyloprim)
Rationale: Improves renal excretion of toxic byproducts from the breakdown of leukemia cells. Reduces the chances of nephropathy as a result of uric acid production.
Potassium acetate or citrate, sodium bicarbonate
Rationale: May be used to alkalinizing the urine, preventing or minimizing tumor lysis syndrome/kidney stones.
Stool softeners.
Rationale: Helpful in reducing straining at stool with trauma to rectal tissues.
Bleeding Precautions
Monitor laboratory studies, e.g., platelets, Hb/Hct, clotting.
Rationale: When the platelet count is less than 20,000/mm (because of the proliferation of WBCs and/or bone marrow suppression secondary to antineoplastic drugs), the patient is prone to spontaneous life-threatening bleeding. Decreasing Hb/Hct is indicative of bleeding (maybe occult).
Collaborative
Administer RBCs, platelets, clotting factors.
Rationale: Restores/normalizes RBC count and oxygen-carrying capacity to correct anemia. Used to prevent/treat hemorrhage.
Maintain external central vascular access device (subclavian or tunneled catheter or implanted port).
Rationale: Eliminate peripheral venipuncture as a source of bleeding.
Administer medications, e.g., oral contraceptives
Rationale: Minimizes blood loss by stopping or slowing the menstrual flow.
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Nursing Care Plan 3: Diagnosis – Pain, acute
May be related to:
- Physical agents, e.g., enlarged organs/lymph nodes, bone marrow packed with leukemic cells
- Chemical agents, e.g., antileukemic treatments
- Psychological manifestations, e.g., anxiety, fear.
Possibly evidenced by:
- Reports of pain (bone, nerve, headaches, and so forth)
- Guarding/distraction behaviors, facial grimacing, alteration in muscle tone
- Autonomic responses
Desired outcomes
Patient will:
Pain Level (NOC)
- Report pain is relieved/controlled.
- Appear relaxed and able to sleep/rest appropriately.
Pain Control (NOC)
- Demonstrate behaviors to manage pain.
Nursing Intervention
Pain Management
Independent
Investigate reports of pain. Note changes in degree (use scale of 0–10) and site.
Rationale: Helpful in assessing the need for intervention; may indicate developing complications.
Monitor vital signs note nonverbal cues, e.g., muscle tension, restlessness.
Rationale: May be useful in evaluating verbal comments and the effectiveness of interventions.
Provide a quiet environment and reduce stressful stimuli, e.g., noise, lighting, constant interruptions.
Rationale: Promotes rest and enhances coping abilities.
Place in a position of comfort and support joints, extremities with pillows/padding.
Rationale: May decrease associated bone/joint discomfort.
Reposition periodically and provide/assist with gentle ROM exercises.
Rationale: Improves tissue circulation and joint mobility.
Provide comfort measures (e.g., massage, cool packs) and psychological support (e.g., encouragement, presence).
Rationale: Minimizes need for/enhances effects of medication.
Review/promote patient’s own comfort interventions, e.g., position, physical activity/nonactivity, and so forth.
Rationale: Successful management of pain requires patient involvement. The use of effective techniques provides positive reinforcement, promotes a sense of control, and prepares patients for interventions to be used after discharge.
Evaluate and support the patient’s coping mechanisms.
Rationale: Using own learned perceptions/behaviors to manage pain can help the patient cope more effectively.
Encourage use of stress management techniques, e.g., relaxation/deep-breathing exercises, guided imagery, visualization, Therapeutic Touch.
Rationale: Facilitates relaxation, augments pharmacological therapy, and enhances coping abilities.
Assist with/provide diversional activities relaxation techniques.
Rationale: Helps with pain management by redirecting attention.
Collaborative
Monitor uric acid level as appropriate.
Rationale: Rapid turnover and destruction of leukemic cells during chemotherapy can elevate uric acid, causing swollen, painful joints in some patients. Note: Massive infiltration of WBCs into joints can also result in intense pain.
Administer medications as indicated: Analgesics, e.g., acetaminophen (Tylenol)
Rationale: Given for mild pain not relieved by comfort measures.Note: Avoid aspirin-containing products because they may potentiate hemorrhage.
Opioids, e.g., codeine, morphine, hydromorphone (Dilaudid).
Rationale: Used around-the-clock, rather than prn, when pain is severe. Note: The use of patient-controlled analgesia (PCA) is beneficial in preventing peaks and valleys associated with intermittent drug administration and increases the patient’s sense of control.
Antianxiety agents, e.g., diazepam (Valium), lorazepam (Ativan).
Rationale: May be given to enhance the action of analgesics/opioids.
Nursing Care Plan 4: Diagnosis – Activity intolerance
May be related to:
- Generalized weakness; reduced energy stores, increased metabolic rate from massive production of leukocytes
- Imbalance between oxygen supply and demand (anemia/hypoxia)
- Therapeutic restrictions (isolation/bedrest); effect of drug therapy
Possibly evidenced by:
- Verbal report of fatigue or weakness
- Exertional discomfort or dyspnea
- Abnormal HR or BP response
Desired outcomes
Patient will:
- Report a measurable increase in activity tolerance.
- Participate in ADLs to a level of ability.
- Demonstrate a decrease in physiological signs of intolerance; e.g., pulse, respiration, and BP remain within the patient’s normal range.
Nursing Intervention
Energy Management
Independent
Evaluate reports of fatigue, noting inability to participate in activities or ADLs.
Rationale: Effects of leukemia, anemia, and chemotherapy may be cumulative (especially during acute and active treatment phase), necessitating assistance.
Encourage the patient to keep a diary of daily routines and energy levels, noting activities that increase fatigue.
Rationale: Helps patient prioritize activities and arrange them around fatigue patterns.
Provide a quiet environment and uninterrupted rest periods. Encourage rest periods before meals.
Rationale: Restores energy needed for activity and cellular regeneration/tissue healing.
Implement energy-saving techniques, e.g., sitting, rather than standing, use of shower chair. Assist with ambulation/other activities as indicated.
Rationale: Maximizes available energy for self-care tasks.
Schedule meals around chemotherapy. Give oral hygiene before meals and administer antiemetics as indicated.
Rationale: May enhance intake by reducing nausea.
Recommend small, nutritious, high-protein meals and snacks throughout the day.
Rationale: Smaller meals require less energy for digestion than larger meals. Increased intake provides fuel for energy.
Collaborative
Provide supplemental oxygen.
Rationale: Maximizes oxygen available for cellular uptake, improving tolerance of activity.
