Med-Surg: Chapter 34: Leukemia Flashcards

1
Q

Leukemia

A

White blood cell disorder

  • malignant disease or “blood cancer”
  • disorder of the bone marrow in which WBCs begin multiplying uncontrollably
  • acute or chronic
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2
Q

4 Major Leukemias

A
  • acute myelogenous leukemia (AML)
  • chronic myelogenous leukemia (CML)
  • acute lymphoblastic leukemia (ALL)
  • chronic lymphocytic leukemia (CLL)
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3
Q

Risk Factors

A
  • downs syndrome
  • presence of philadelphia chromosome (abnormal chromosome 22)
  • exposure to radiation or benzene
  • smoking
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4
Q

Pathophysiology

A

an unknown stimulus mutates either a myeloid or lymphoid stem cell

  • this single cell clones itself, producing an immature WBC known as a leukemic cell, or blast, in which never matures as a result of the mutation
  • this cloning process becomes uncontrollable, filling the bone marrow with these leukemic cells, which gets pushed into the circulation
  • this uncontrollable production of WBCs is called leukocytosis
  • b/c of the mutation, these WBCs never mature and do not respond to the normal signal that leads to programmed cell death, or apoptosis
  • the bone marrow, spleen, and lymph tissue become congested with the blasts, leading to lymphadenopathies, splenomegaly, and infiltration of the body’s mucous membranes and lungs
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5
Q

Leukocytosis

A

uncontrollable production of WBCs

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6
Q

Clinical Manifestations

A

secondary to the blast congestion, lymph glands in the neck, axillae, or groin and the left upper abdominal quadrant may become swollen and painful

  • risk of infection is increased b/c these leukemic WBCs do not mature; therefore, the number of mature infection-fighting cells, or neutrophils, decreases (neutropenia)
  • low grade fevers in response to minor infections
  • major infections (pneumonia) usually do not occur until after chemotherapy initiation, which can cause profound neutropenia where the absolute neutrophil count (ANC) is less than 1000 mm3
  • as leukemia progresses, the bone marrow, which is congested with leukemic cells, is not able to adequately produce RBCs and Platelets; often present with clinical manifestations of anemia (fatigue, palloe, weakness, SOB, and bruising, petechiae, nosebleeds, and bleeding gums from the decreased number of platelets
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7
Q

Diagnosis

A
  • presents to provider with complaints of flu-like symptoms (fatigue, low-grade fever, pallor)
  • routine CBC reveals the leukemia; reveals leukocytosis (or increased WBC count); and demonstrates anemia and thrombocytopenia (low platelets) that occur as a result of congested bone marrow
  • history and physical exam performed
  • confirmation of the diagnosis usually follows a bone marrow biopsy that shows the type of leukemia and extent of the malignancy
  • genetic testing can be performed to determine any chromosomal abnormalities
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8
Q

Systemic Chemotherapy

A

initiated to destroy the leukemic cells and induce a remission that indicates that the bone marrow is free of leukemic cells and is able to produce health blood cells
-remission does not = cure

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9
Q

Treatment Strategies: Two phases

A
  • remission induction

- post-remission maintenance

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10
Q

Remission Induction

A

includes the initial administration of chemotherapeutic agents
-high doses of chemotherapy are given and may be accompanied by radiation therapy; usually causes the patient to become acutely ill; treatment may be worse than disease

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11
Q

Granulocyte colony stimulating factors (GCSFs)

A

given post-chemotherapy to stimulate the bone marrow to produce neutrophils

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12
Q

Filgrastim

A
  • short acting
  • subcutaneous injection
  • given to prevent development of post-chemotherapeutic infections
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13
Q

Pegfilgrastim

A
  • long-acting
  • subcutaneous injection
  • given to prevent development of post-chemotherapeutic infections
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14
Q

Post-remission maintenance

A

after the induction phase

  • chemotherapy may continue at lower doses and/or less frequently in order to suppress the formation of leukemic cells
  • may continue for months or years
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15
Q

Transplantation

A

-only possibility for a cure
-Bone marrow transplantation (BMT)
-Peripheral stem cell transplantation (PSCT)
-Hematopoietic stem cell transplantation (HSCT)
>donor cells are needed to transplant into the bloodstream (either autologous; patients own, or allogeneic; from a donor)

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16
Q

Graft-versus-host disease (GVHD)

A

when donor bone marrow or stem cells attack the recipient

17
Q

Neutropenic Precautions

A
  • frequent hand washing or the use of alcohol-based hand sanitizer by the patient and others coming into contact with the patient
  • avoid crowds
  • if must go out, mask is indicated
  • avoid obviously sick people, small children, an pets while neutrophil count is low
  • wash all raw vegetables and fruits before eating; avoid raspberries and blackberries that have little bumps and ridges and cannot be washed well
  • monitor temperature daily, contact provider if greater than 100.4
  • for fevers, rigors (shaking chills), and obvious clinical manifestations of illness, seek immediate medical tx; rapid treatment with IV antibiotics is crucial to prevent sepsis and death
  • no live plants or cut flowers in the home environment b/c they breed bacteria and mold
  • avoid standing water in appliances such as humidifiers b/c this breeds mold and bacteria
  • if started on prophylactic antibiotic, antiviral, and antifungal therapies, stress the importance of taking prescribed medications daily and completing entire course of antibiotics
  • requires private room if hospitalized
  • avoid rectal temperatures, suppositories, and enemas b/c of the normal bacteria in the rectum that could enter the bloodstream if there is rectal trauma associated with these interventions
18
Q

Nursing Management: Assessment and Analysis

A

leukemia is usually discovered in a routine CBC b/c the patient is often asymptomatic
-clinical manifestations that may cause a patient to seek medical attention are result of the anemia and thrombocytopenia that occur as a result of the bone marrow being clogged with WBCs

19
Q

Assessment: Clinical Manifestations

A

a result of the anemia and thrombocytopenia that occur as a result of the bone marrow being clogged with WBCs

  • leukocytosis
  • neutropenia
  • anemia (low RBCs)
  • thrombocytopenia (low platelets)
  • SOB; on exertion or lying flat
  • excessive bruising
  • petechiae
  • fatigue
  • pallor
  • dizziness
  • low-grade fevers in response to minor infections
20
Q

Nursing Assessments

A

> Vital Signs
-low-grade fevers in response to minor infections by cuts, abrasions, sores, and so forth occur b/c of the decrease in mature neutrophils needed to produce a more pronounced temperature elevation

> Fatigue, pallor, dizziness, SOB
-manifestations of anemia occur as a result of decreased erythrocytosis b/c the bone marrow is congested with WBCs

> Excessive bruising, petechiae (different from a rash—when you push, petechiae do not blanch)
-clinical manifestations of thrombocytopenia occur as a result of decreased production of platelets b/c the bone marrow is congested with WBCs, and there may be spontaneous bleeding into the subcutaneous tissues

> CBC values

  • leukocytosis of leukemic WBCs occurs from a single mutation
  • the excessive WBCs clog the bone marrow, resulting in decreased production of RBCs and Platelets
21
Q

Nursing Actions

A

> Administer chemotherapy
-started on chemotherapy to destroy the leukemic cells

> Institute neutropenic precautions
-pt needs to take extra precautions to prevent infection due to low neutrophil count

> Prophylactic use of antibiotics, antivirals, and antifungals
-often initiated to provide added protection against infection when the neutrophil count is low

> Administer antibiotics
-when the ANC (absolute neutrophil count) is less than 1,000, it is imperative to start IV antibiotics immediately in order to prevent sepsis and possible death

> Symptom management (nausea/vomiting/diarrhea, ulcerations of the mouth)

  • post-chemotherapy/post-radiation symptom management is continuously assessed to maintain the patient’s quality of life
  • antiemetics or antidiarrheal medication are indicated to minimize discomfort as well as decrease fluid loss

> Administer ordered blood products
-may require blood products as cell cunts (RBCs and platelets) drop b/c of the myelosuppression caused by chemotherapy

22
Q

Teaching

A

> Neutropenic precautions

> Clinical manifestations of anemia

> Manifestations of thrombocytopenia
-essential to seek medical attention for an early signs of bleeding

> bleeding precautions

> diagnosis of leukemia

> adverse reactions of chemotherapy and radiation

> possibility of sterility

  • chemotherapy and radiation can render the patient sterile.
  • educated on alternative methods of family planning, including sperm or egg donation
23
Q

Evaluating Care Outcomes

A

untreated leukemia is a fatal disorder

  • goals of tx are to induce remission for the patient and minimize or prevent complications
  • tx consider effective hen the patient has decreased clinical manifestations of anemia, infection, and bleeding
  • prolonging life and improving the quality of life are important
  • symptom management of the chemotherapy and radiation therapy aid in improving the quality of life
  • at present bone marrow transplant (BMT) and peripheral stem cell transplant (PSCT) is only chance of achieving a cure for leukemia
24
Q

Leukemia: Risk Factors, S/S, Metastasis

A

> Risk Factors:

  • alkylating agents
  • genetic mutations
  • radiation exposure

> S/S:

  • fatigue
  • anemia
  • chronic infection
  • bruising, petechiae, gum bleeding

> Metastasis:
-diffuse at diagnosis