Acute

Lymphocytic
Leukemia

Presented by
Jacob Tabigo-on
Mark Tapang
Introduction

Acute lymphocytic leukemia (ALL) is characterized by excessive accumulation of lymphoblasts

(immature lymphocytes) in the bone marrow, lymph nodes, and spleen as well as in the
circulating blood and fails to function effectively as normal blood cells to maintain immunity.

Lymphoblasts stop the normal bone marrow production of red blood cells, platelets and mature
leucocytes resulting to thrombocytopenia, leukopenia, and anemia. Without treatment, the
client may die of infection or hemorrhage.

Physiology Review

Most blood cells are formed in the bone marrow, (the soft material in the center of most
bones) called stem cells.

Stem cells mature into different kinds of blood cells of which each kind has special functions:

a. White blood cells (also called WBCs or leukocytes), help the body fight infections and other
diseases.

b. Red blood cells (also called RBCs or erythrocytes) carry oxygen from the lungs to the bodys
tissues and take carbon dioxide from the tissues back to the lungs. The red blood cells give
blood its color.

c. Platelets (also called thrombocytes) help form blood clots that control bleeding

New or immature blood cells are called blasts. Some blasts stay in the marrow to mature while
some travel to other parts of the body to mature. When the blood cells grow old or get
damaged, they die, and new cells will form again. This picture shows how stem cells mature
into 2different types of white blood cells.

a. A myeloid stem cell matures into a myeloid blast, which further differentiate into
granulocytes, neutrophil, eosinophil and basophils
b. A lymphoid stem cell matures into a lymphoid blast which further differentiate into
lymphoid tissue such as B cells and T cells.
Leukemias are classified based on how quickly the disease develops and gets worse. It can be
either Chronic (which usually gets worse slowly) or Acute (which usually gets worse quickly)

a. Chronic leukemia

It is characterized by an abnormal mature-appearing cell.

b. Acute leukemia

It is characterized by a rapid disease progression and immature or undifferentiated blast cells.

They are aggressive tumors that reach a climax within few weeks or months

The types of leukemia also can be grouped based on the type of white blood cell that is
affected, namely lymphoid cells or myeloid cells:

A. Lymphocytic(or lymphoblastic)

Leukemias involve immature lymphocytes and their precursor cells in the bone marrow. It also
penetrates the spleen, lymph nodes, CNS and other tissues.

Acute lymphoblastic leukemia(ALL) is most common in children while chronic lymphoblastic

leukemia(CLL) affects older adults.

b. Myeloid (also known as myelogenous, myelocytic or myeloblastic) leukemia.

This involves the myeloid stem cells in the bone marrow, intervening with the maturation of all
types of blood cells, including granulocytes, RBCs, and thrombocytes. This affects mostly on
adult people.
Epidemiology

ALL is the most common type of childhood cancer. It most often occurs in children ages 3 to 5
and affects slightly more boys than girls.

About 3,000 people younger than age 20 are found to have ALL each year in the United States.

Siblings of children with leukemia have a slightly higher risk of developing ALL, but the rate is
still quite low: no more than 1 in 500.\

The incidence of ALL appears to be highest in Hispanic children (43 cases per 1 million).

The incidence is substantially higher in white children than in black children, with a nearly
threefold higher incidence of ALL from age 2 to 3 years in white children than in black children

Predisposing Factors
The exact cause of leukemia is not clear. However, few have been associated with an increased
risk of developing the disease:

Radiation: People exposed to very high levels of radiation are much more likely than others to
get acute myeloid leukemia, chronic myeloid leukemia, or acute lymphocytic leukemia. (e.g.
Atomic bomb explosions, Radiation therapy, Diagnostic X-rays)

Chemotherapy: Cancer patients treated with certain types of cancer-fighting drugs sometimes
later get acute myeloid leukemia or acute lymphocytic leukemia e.g., alkylating agents or
topoisomerase inhibitors is linked with a small chance of later developing acute leukemia.

Down Syndrome and certain other inherited disease increase the risk of acute leukemia
Patients Profile
Name: I.L.

Age: 15 years old

Birthdate: 02/03/2002

Education: Grade 7 (ongoing)

Gender: Male

Language: English and Tagalog

Date Admitted: 2/5/15 2:19 pm

Present Health History

Patient came in for scheduled bone marrow aspiration biopsy and testicular biopsy. He is a
diagnosed case of Acute lymphocytic leukemia (2011) s/p intrathecal chemotherapy and bone
marrow aspiration (9/16/14) biopsy and is currently on the maintenance phase.

Past Health History

Had chicken pox at 2004
Measles at 2007
2011, ALL maintained on mercaptopurine 50mg/tab OD, Methotrexate 2.5 mg/tab and
Prednisone 30mf/tab.
May 2014, had cough and colds w/ fever

Social History
Patient lives with his parents and older sibling; daily activities include watching tv, attending
school and playing outside.
Family History
Maternal Benign breast cyst, breast cancer, goiter

Paternal Hypertension and Leukemia

Gordons Functional Health Pattern

Before During Diagnosis
Hospitalization Hospitalization
1. Health Perception and
Management Pattern.

"Mahilig yung anak ko sa

gulay at isda. Hindi siya "Hindi naman siya nagkaron ng
umiinom o naninigarilyo. sakit dito sa hospital, natutulog
Mga dalawang isang beses lang siya kapag walang
lang siya nilagnat noong ginagawa," as verbalized by
isang taon. Tska lahat the mother.
vaccinated siya. Na-admit
yung anak ko dahil sa ALL
niya, tapos mag biopsy na
lang siya ngayun," as
verbalized by the mother.

2. Nutritional and
Metabolism

"Tatlong beses siya

kumakain sa isang araw. "Yung kinakain niya ngayun eh
Mahilig siya sa ma-sabaw yung pagkain sa canteen,
na pagkain katulad ng yung beefsteak, meatballs.
sinigang na isda. Mga 8-9 Mga 5-6 lang ng baso ng tubig
na baso ng tubig ang ang naiinom niya," as
naiinom niya," as verbalized verbalized by the mother.
 by the mother.

3. Elimination Pattern

"Siguro mga apat o limang "Isang beses pa lang siya umihi

beses sa isang araw siya at hindi pa siya nakakdumi
dumudumi, paiba-iba eh. ngayun," as verbalized by the
Sa pag ihi madami, mga 4 mother.
o 5 siguro, wala naman,
hindi siya hirap," as
verbalized by the mother.

4. Activity-Exercise Pattern

"Mahilig siya sa basketball.

Lagi siya naglalaro kasama
niya kuya at kaibigan niya, "Ngayun, wala kasi nakahiga
tapos pag sabado lang siya. Maglalakad kapag
nagjojogging sila mga 8AM pupunta ng C.R. yun lang," as
hanggang 9AM lang." as verbalized by the mother.
verbalized by the mother.
 5. Sleep-Rest Pattern

"Nako, mga 11PM na "Mga 10 hours na siya tulog

natutulog yan. Nag ngayun, gigisingin lang siya
cocomputer kasi. Tapos kapag i-vital signs siya," as
gigisingin ko ng 6AM yan verbalized by the mother.
kasi maaga pasok, " as
verbalized by the mother.

6. Cognitive and Perceptual

"Wala okay naman yung sa "Wala, perahas din. Walang

mata niya at walang problema sa mata at
hearing aid. Kapag pandinig," as verbalized by the
tuturuan siya, gusto niya mother
siya lang kasi kaya na daw
niya," as verbalized by the
mother

7. Self-Perception- Self
Concept

"Ngayun, okay lang naman

"Mahiyain yung anak ko. siya, walang masakit sa kanya,"
Mabait naman, nasasaway as verbalized by the mother.
naman din siya," as
verbalized by the mother.

8. Role-Relationship Pattern

"Kapag wala kami sa "Yung asawa ko nag ttrabaho

bahay ng asawa ko, yung kasi, ako nag babantay dito,"
kuya niya kasama niya. Sa as verbalized by the mother.
liquid station ako sa fire
staion ng government, yung
asawa ko naman
kundoktor," as verbalized by
 the mother.

9. Sexuality-Reproductive
Pattern

""Wala naman. Okay lang

"Sabi nila may girlfriend na naman siya," as verbalized by
"daw", pero ewan ko," as the mother.
verbalized by the mother.

10. Coping-Stress Pattern

"Nag co-computer lang yan "Nanunuod lang siya sa tablet

kapag stress o nag lalaro ng ng movies sa youtube," as
basketball sa labas," as verbalized by the mother.
verbalized by the mother.

11. Values- Belief Pattern

"Roman Catholic kami "Nakakatulong Siya lalo na sa

tuwing Linggo nagsisimba sitwasyong ganto," as
kaming pamilya," as verbalized by the mother.
verbalized by the mother.

Laboratory Results
Test Results Normal Range
Specimen CFS

Color Xanthocochromic Colorless

Turbidity Slightly Turbid Clear
Pellicle Negative Negative
Cell Count

WBC 1 X10^g/L
Lymphocyte 100%
Neutrophil
RBC 1,800 X10^g/L
Prothrombin Time 14.1 sec 10-15
Control 12.0 sec
INR 1.18
% Activity 78.1
Partial thromboplastin time 31.3 sec 29-34
Control 30.0
Bleeding Time 200 min 1-3

Clinical Manifestations
Leukemia like other blood cells, travel through the body where it influences the health and
function of all organs and systems.

Symptoms may vary from one person to another, depending on the number of leukemic cells
and where these cells collect in the body. But generally, manifestation of leukemia results from
anemia, infection and bleeding.

These include pallor, fatigue, tachycardia, malaise, lethargy, and dyspnea on exertion.

General Signs and Symptoms

Fever

Lost of appetite

Joint/Bone pain

Weakness

Spleen Enlargement (Splenomegaly)

Hepatomegaly

Systemic Infections

Bleeding
 Anemia

Headache

Vomiting

Lymphadenopathy

Seizures
Clinical Investigations
o Physical Exam - Checks for swollen lymph nodes, spleen, or liver.

o Blood Tests Complete blood count to check the number of white blood cells, red
blood cells, and platelets. Leukemia causes a very high level of white blood cells. It may
also cause low levels of platelets and hemoglobin, which is found inside red blood cells.

o Biopsy - Removal of tissue of the bone marrow in the hipbone or other large bone to
look for cancer cells. It is the only way to know whether leukemia cells are in the bone
marrow. There are two ways how to obtain sample of the bone marrow, some physician
do both at the same time:

1. Bone Marrow Aspiration - The doctor uses a thick, hollow needle to remove samples
of bone marrow.

2. Bone Marrow Biopsy - The doctor uses a very thick, hollow needle to remove a small
piece of bone and bone marrow.

o Chemotherapy - This is the treatment choice of most types of leukemia, with a goal
of eradicating leukemic cells and producing remission. Children with this disease are
likely to be cured and a number of adult patients have high remissions. Generally,
chemotherapy is divided into 2 phases: induction phase therapy and post-remission
therapy

a. Induction Phase.

During this phase drugs doses are high to eradicate leukemic cells from the bone
marrow. A combination of drugs is used such as daunorubin (cerubidine, an antitumor
 antibiotic) with vincristine (oncovin, a plant alkaloid) with prednisone with asparaginase
(elspar).

These high doses of drug often damage the stem cells and interfere with the production
of normal blood cells but circulating mature blood cells are not affected because they
are no longer dividing.

b. Post-remission Therapy.

Once remission is achieved, post remission chemotherapy is continued to eradicate any

additional leukemic cells, prevent relapse, and prolong survival. A single chemotherapy
agent, combination therapy or bone marrow transplant may be used for post remission
treatment

o Radiation Therapy

(also called radiotherapy) uses high-energy rays to kill leukemia cells. Radiotherapy
damages cellular DNA.

Though the leukemic cells continue to function, it cannot divide and multiply e.g., cells
in bone marrow and cancer cells divides rapidly and respond quickly to radiation
therapy.

Radiotherapy is also aimed at the spleen, the brain, or other parts of the body where
leukemia cells have collected.

o Biologic Therapy
Interferon and interleukin (cytokines) may be used to treat leukemias. They modify the
bodys response to cancer cells, moderate immune function and inhibit abnormal cell
proliferation and growth.

o Bone Marrow Transplant

This is often used in conjunction with chemotherapy or radiation. There are 2

categories:

1. Allogenic BMT.
 Uses the bone marrow of a healthy donor (usually from a sibling/unrelated closed
matched antigen. The donors bone marrow is aspirated and is infused through a central
venous line into the recipient.

2. Autologous BMT (or bone marrow rescue).

Uses the client own bone marrow to restore the bone marrow function after
chemotherapy or radiation. During the period of disease remission, about 1L of bone
marrow is aspirated from the patient. It is then stored and frozen for use after
treatment of chemotherapy or radiation, with the aim of destroying the immune system
and malignant cells and to prepare space in the bone marrow for new cells.

The filtered bone marrow is thawed and infused intravenously through central line and
slowly become part of the clients bone marrow, neutrophil count increases, and normal
haematopoiesis takes place.

o Allogeneic Stem Cell Transplant

Is a replacement of the recipients blood cell lines(WBCs, RBCs, and platelets) with cells
derived from the donor stem cells.

This is an alternative to bone marrow transplant.

The recipient and the donor tissue must be closely matched prior to harvesting and
necessary procedure and treatment are conducted prior to harvesting to prevent the
risk of infection and other complications
 Medications
Name Mechanism of Indication Contraindication Side Nursing
Action
effects Responsibility

Cefuroxime Bactericidal Treatment of for Contraindicated in Diarrhea, Before giving

antibiotic, bacterial patients Anorexia, dug. ask patient if
which exerts infection hypersensitive to Vomiting she is allergic to
antibacterial drug or other penicillin or
activity by cephalosporin. cephalosporin.
inhibition of
bacterial cell
wall synthesis in
susceptible
species.

Ibuprofen The exact Pain Contraindicated Mild -Monitor liver

mechanism of to patients with heartburn, function studies
action of asthma diarrhea, may cause hepatic
ibuprofen is dizziness, toxicity.
unknown. headache
Ibuprofen is a
non-selective -Assess for fever and
inhibitor of pain.
cyclooxygenase,
an enzyme
invovled in
-Assess for
prostaglandin
allergic reactions
synthesis via
(rashes)
the arachidonic
acid pathway.
Prednisone Prednisolone Immune system Contraindicated Heartburn, -Monitor vital
irreversibly disorder with patients with muscle signs
binds ulcer weakness,
with glucocortic irritability.
oid receptors -Monitor for
alpha and beta withdrawal
for which they syndrome (fever,
have a high fatigue, dizziness)
affinity.
 NCP
Risk for Infection
Assessment Diagnosis Planning Intervention Rationale Evaluation
STG Noted risk To After hours of
S> Nag diagnosed Risk for factors for prevent/reduce nursing
kasi anak ko noong infection r/t After 4 hours occurrence of the risk for intervention, client
2011 ng ALL. As inadequate of nursing infection infection has verbalized the
verbalized by secondary intervention, understanding of
patients mother defenses client will Noted signs For immediate individual risk
verbalize and care to be factors and has
O> Child is passive, understanding symptoms of given demonstrated
alert and awake on of individual sepsis techniques,
bed, has good risk factors To promote lifestyle changes to
appetite and no Reviewed clients promote safe
complaints. Vital LTG individual wellbeing environment.
Signs: nutritional
100/60, 36.5oC, 98, Demonstrate needs,
17 techniques, appropriate
lifestyle exercise
changes to program and
promote safe need for rest.
environment To follow the
Emphasized doctors order
necessity of
taking
antivirals or
antibiotics as
directed
To
Instructed prevent/reduce
client in risk of infection
techniques to
protect the
integrity of
skin, care for
lesions, and
prevention of
spread of
infection.
 Risk for Powerlessness
Assessment Diagnosis Planning Intervention Rationale Evaluation
STG After 4 hours of
S> Wala naman Risk for Established To promote nursing
masakit sa kanya, powerlessness After 4 hours rapport trust and intervention, client
okay lang naman r/t Illness of nursing cooperation has identified areas
daw sya. As intervention, Listened to with client over which
verbalized by client will clients individual has
clients mother. identify areas perception of To be able to control and is able
over which the situation understand to make choices
O> Awake and individual has the related to, and
alert; Shy, distant control Encouraged perspective involved in care.
and recently had client to think of the client
circumcision, has LTG productively
been passive and and positively To give hope
dependent on Client will be to client
mother. able to make Encouraged
choices client to be To be able to
Vital Signs: related to active in long- be involved in
100/60, 36.5oC, 98, and be term care.
17 involved in healthcare
care. management.

Risk for Infection

Assessment Diagnosis Planning Intervention Rationale Evaluation

O> Weak in Risk for After 6 hours of -Observed -To be able to After 6 hours of
appearance, infection r/t nursing localized signs know the nursing
undergone post intervention, of infection existence of intervention,
circumcision operational the client will infection the client
with open wound remain free remained free
wound, 100/60, from any signs -Encouraged from any signs
of infection. mother to limit -To limit of infection
36.5 C, 98,17
visitors spread of
infection in
the room
-Taught client
on proper hand
washing and
-To prevent
perineal care.
spread of
-Instructed bacteria
client on how
to perform
correct way of -To promote
dressing the comfort
wound