Acute Lymphocytic Leukemia Nursing Care Management: Study Guide

Acute lymphocytic leukemia floods the marrow with immature lymphoblasts that crowd out everything the patient needs to survive: red cells, platelets, and functioning white cells. So the bedside picture is anemia, bleeding, and infection all at once. Untreated, it is fatal. Your work is protecting the neutropenic, bleeding-prone patient and getting them through chemotherapy.

What is Acute Lymphocytic Leukemia?

Acute leukemias carry large numbers of immature leukocytes and overproduce cells stuck in the blast stage of maturation.

Acute lymphocytic leukemia (ALL), also called acute lymphoblastic leukemia, is an abnormal growth of lymphocyte precursors (lymphoblasts). It is a malignant proliferation of white blood cell precursors in bone marrow or lymph tissue, with accumulation in peripheral blood, bone marrow, and body tissues. About 20% of leukemias are acute.

Pathophysiology

The pathogenesis is not fully understood, but it runs in three steps. Accumulation: immature, nonfunctioning WBCs first build up in the tissue where they originate (lymphocytes in lymph tissue, granulocytes in bone marrow). Infiltration: these immature WBCs spill into the bloodstream and infiltrate other tissues. Malfunction: the infiltration causes organ malfunction through encroachment and hemorrhage.

Statistics and Incidences

ALL is one of the most common forms of acute leukemia. It is more common in males than females, in whites (especially people of Jewish descent), in children between ages 2 and 5, and in people in urban and industrialized areas. 80% of all leukemias in children 2 to 5 years old are ALL. Acute leukemias account for 20% of adult leukemias. Among children, ALL is the most common cancer. Incidence is 6 out of every 100,000 people.

Causes

Research on predisposing factors is not conclusive but points to some mix of viruses, immunologic factors, genetic factors, and exposure to radiation and certain chemicals. Congenital disorders such as Down syndrome, Bloom syndrome, Fanconi anemia, congenital agammaglobulinemia, and ataxia-telangiectasia predispose to ALL. Genetics also play a part (familial tendency). Viral remnants have been found in leukemic cells, so viruses are a likely contributor.

Clinical Manifestations

Signs may come on gradually or abruptly. High fever with thrombocytopenia and abnormal bleeding (nosebleeds, gingival bleeding). Easy bruising after minor trauma. Dyspnea as mature blood components fall. Anemia from decreased mature RBCs. Fatigue more often than normal. Tachycardia, as the body compensates for the falling oxygen-carrying capacity of the blood.

Complications

Untreated, acute leukemia is invariably fatal, usually from complications of leukemic cell infiltration of the bone marrow and vital organs. Infection: immature WBCs cannot defend against pathogens, so infection is always a threat. Organ malfunction: encroachment or hemorrhage as immature WBCs spill into the bloodstream and tissues.

Assessment and Diagnostic Findings

Bone marrow aspiration. Typical clinical findings plus a marrow aspirate showing proliferation of immature WBCs confirm ALL.

Bone marrow biopsy. Usually of the posterior superior iliac spine, part of the diagnostic workup.

Blood counts. Show severe anemia, thrombocytopenia, and neutropenia.

Differential leukocyte count. Determines cell type.

Lumbar puncture. Detects meningeal involvement.

Uric acid levels. Elevated uric acid and lactic dehydrogenase levels are common.

Medical Management

With treatment, the prognosis varies. Systemic chemotherapy aims to eradicate leukemic cells and induce remission (less than 5% blast cells in the marrow, with normal peripheral blood). Radiation therapy is given for testicular infiltrations. Platelet transfusion prevents bleeding and RBC transfusion prevents anemia.

Pharmacologic Therapy

ALL chemotherapy includes these drugs among others. Vincristine, an antineoplastic plant alkaloid. Prednisone, which alters the body's normal immune responses. Cytarabine, an antimetabolite; once cells incorporate it into their metabolism they cannot divide, and it strikes cells at specific phases of the cycle. L-asparaginase breaks down asparagine, and since the cancer cells cannot make their own, they die. Daunorubicin, an antitumor antibiotic derived from the soil fungus Streptomyces, acting during multiple phases of the cell cycle. Antibiotics, antifungals, and antivirals control infection, a common complication of acute leukemias.

Surgical Management

Bone marrow transplant is an option for a patient with ALL. Stem cell transplant is one of the newer approaches in treating acute leukemias.

Nursing Management

The care plan emphasizes comfort, minimizing chemotherapy side effects, preserving veins, managing complications, and providing teaching and psychological support.

Nursing Assessment

The clinical picture varies with the leukemia type and the treatment, so assess the following. Health history, which may reveal subtle symptoms the patient reports before anything shows on exam. Physical examination, a thorough systematic assessment of all body systems. Laboratory results, closely monitored, with culture results reported immediately.

Nursing Diagnosis

Based on assessment data, major nursing diagnoses may include risk for infection related to overproduction of immature WBCs; risk for impaired skin integrity related to toxic effects of chemotherapy, altered nutrition, and impaired mobility; imbalanced nutrition, less than body requirements, related to a hypermetabolic state, anorexia, mucositis, pain, and nausea; acute pain and discomfort related to mucositis, leukocyte infiltration of tissues, fever, and infection; hyperthermia related to tumor lysis or infection; and fatigue and activity intolerance related to anemia, infection, and deconditioning.

Nursing Care Planning & Goals

Major goals: absence of pain, attainment and maintenance of adequate nutrition, activity tolerance, ability to provide self-care and cope with the diagnosis and prognosis, and positive body image.

Nursing Interventions

Before treatment: Explain the disease course, treatment, and side effects. Teach the patient and family to recognize signs of infection (fever, chills, cough, sore throat). Teach them to recognize abnormal bleeding through bruising and petechiae and to stop it with direct pressure and ice. Promote good nutrition, explaining that chemotherapy causes weight loss and anorexia, so push high-calorie, high-protein foods and drinks. Help set up an appropriate rehabilitation program for use during remission.

Plan meticulous supportive care: Watch for meningeal leukemia (confusion, lethargy, headache) and manage care after intrathecal chemotherapy. Prevent hyperuricemia from rapid chemotherapy-induced cell lysis by encouraging fluids to 2000 ml daily and giving acetazolamide, sodium bicarbonate tablets, and allopurinol. Control infection with a private room and neutropenic precautions. Provide thorough skin care, keeping the skin and perianal area clean, applying mild lotions to prevent cracking and drying, and cleaning skin before all invasive procedures. Prevent constipation with adequate hydration, a high-residue diet, stool softeners, mild laxatives, and walking. Control mouth ulceration by checking often for ulcers and gum swelling and providing frequent mouth care and saline rinses. Provide psychological support by building a trusting relationship. Minimize stress with a calm, quiet atmosphere.

Evaluation

Expected outcomes: no evidence of infection, no bleeding, optimal nutrition, satisfaction with pain and comfort levels, less fatigue with increased activity, coping with anxiety and grief, and absence of complications.

Discharge and Home Care Guidelines

Most patients cope better when they understand what is happening to them. Base teaching on the patient's education, literacy level, and interest, focusing on the disease, its treatment, and the resulting significant risk of infection and bleeding. Most patients or family members can be taught to manage a vascular access device, and nurses may need to provide followup care. Coordinate home care services and instruction to ease anxiety about managing care at home.

Documentation Guidelines

Document recent or current antibiotic therapy; signs and symptoms of infection; individual risk factors for blood loss; baseline vital signs, mentation, urinary output, and subsequent assessments; results of laboratory tests and diagnostic procedures; the client's description of pain and pain-management expectations; caloric intake; cultural or religious restrictions and personal preferences; the plan of care; the teaching plan; responses to interventions and teaching; progress toward desired outcomes; modifications to the plan of care; discharge needs; and specific referrals made.