IQRA COLLEGE OF NURSING SCIENCES, DUTSE, JIGAWA STATE.

MEDICAL SURGICAL NURSING LECTURE NOTE FOR SET 1 STUDENT

LEUKAEMIA
INTRODUCTION:
Leukemia, literally “white blood,” is a neoplastic proliferation of one particular cell type
(granulocytes, monocytes, lymphocytes, or megakaryocytes). The defect originates in the
hematopoietic stem cell, the myeloid, or the lymphoid stem cell. The lymphomas are neoplasms of
lymphoid tissue, usually derived from B lymphocytes.
The common feature of the leukemias is an unregulated proliferation of WBCs in the bone marrow.
Leukaemia is a general term used to describe a group of malignant disorder, affecting the
blood and blood forming tissues of the bone marrow, lymphatic system and spleen. It results
in an accumulation of dysfunctional cells because of a loss of regulation in cell division. It
follows a progressive course that is eventually fatal if untreated. Leukaemia occurs in all age
groups.
Hematopoiesis. Uncommitted (pluripotent) stem cells can differentiate into myeloid or lymphoid
stem cells. These stem cells then undergo a complex process of differentiation and maturation into
normal cells that are released into the circulation. The myeloid stem cell is responsible not only for
all nonlymphoid white blood cells (WBCs) but also for the production of red blood cells (RBCs) and
platelets. Each step of the differentiation process depends in part on the presence of specific growth
factors for each cell type. When the stem cells are dysfunctional, they may respond inadequately to
the need for more cells, or they may respond excessively, sometimes uncontrollably, as in leukemia.

AETIOLOGY
There is generally no known single cause in the development of leukaemia.
Most results from combination of predisposing factors including genetic and environmental
influences.
Persons with specific chromosomal aberrations such as occurs with Down syndrome, Von
Recklingh-ausens neurofibromatosis and Fanconi’s anaemia, have an increased incidence of
acute leukaemia.
Chronic exposure to chemicals such as benzene, drugs that caus aplastic anemia, and
radiation exposure have been associated with an increased incidence of the disease.
An increased risk for development of acute leukaemia has been noted after cytotoxic therapy
for Hodgkin’s disease, non-Hodgking’s lymphoma, multiple myeloma, polycythemia vera
and breast, lung and testicular cancers.
CLASSIFICATION OF LEUKAMIAS
The leukaemias are classified as acute or chronic and are further divided according to cell
type or maturity.
 ACUTE LEUKAEMIA: This is characterized by the clonal proliferation of
immature hematopoietic cells. The leukaemia arises following malignant
transformation of a single hematopoietic progenitore, followed by cellular replication
and expansion of the transformed clone. The most prominent characteristic of the
neoplastic cell in acute leukaemia is a defect if maturation beyond the myeloblast or
promyelocyte level in AML and the lymphoblast level as ALL. Acute leukaemias are
subclassified as acute lymphoitic leukaemia (ALL) or acute non-lymphoietic
leukaemia (ANLL) according to the specific morphology of the leukaemia cell.
ANLL further classified as acute myelogenous leukaemia (AML) promelocytic
leukaemia, monocytic leukaemia and other varities according to cell type.
CHRONIC LEUKAEMIA: This may be lymphocytic as in chronic lymphocytic
leukaemia (CLL) or granulocytic as in chronic granulocytic or myelogenous
leukaemia (CMD).
1. ACUTE LYMPHOCYTIC LEUKAEMIA (ALL)
Acute lymphoblastic leukemia (acute lymphocytic leukemia, ALL) is a malignant (clonal)
disease of the bone marrow in which early lymphoid precursors proliferate and replace the
normal hematopoietic cells of the marrow. ALL is the most common type of cancer and
leukemia in children in the United States.
Incidence: It usually occurs before 14 years of age, with peak incidence occurring between
2-9 years of age.
DIAGNOSIS
 The diagnosis is confirmed by bone marrow aspirations or Biopsy which typically
shows different stages of lymphoid development, from very immature to almost
normal cells. The degree of immaturity is a guide to the prognosis, the greater the
number of immature cells, the poorer the prognosis will be.
 CBC usually reveals; low RBC count, Hb, Hct, low platelet count.
 A blood smear and CSF may also show immature lymph blasts.
Clinical manifestations
Anaemia, bleeding, lymphadenopathy, and a predisposition infection. Clinical manifestations
include fever, pallor, bleeding, anorexia, fatigue, and weakness, bone, joint and abdominal
pain, generalised lymphadenopathy, infections of respiratory tract, bleeding of mucous
membrane, weight loss, hepatomegaly, headache, mouth sores. Neurologic manifestations
include; increased intra cranial pressure secondary to meningeal infiltration.
MANAGEMENT
Treatment of ALL include use of chemotherapeutic agents. Untreated patients have a mean
survival of MST from 4 to 6 months, with current chemotherapeutic regimen MST is close to
5 years.
Chemotherapeutic protocol for ALL involve 3 phases;
1. Induction: Often using Vincristine and Prednisone
2. Consolidation: Using modified course of intensive therapy to eradicate any remaining
disease.
3. Maintenance: Usually combination of drugs including the antimetabolites 6-
mercaptopurine and methotrexate.
  The use of prophylactic treatment of the CNS (intrathecal administration of
methotrexate with or without craniospinal radiation) will eradicate leukaemia cells.
 Patients are advised to eat diet that contains high in protein, fibre and fluids; avoid
infection (by hand washing, and avoiding crowds) and injury.
 Take measure to avoid nausea and promote appetite. Maintain oral hygiene.
 Smoking and spicy and hot foods may alter taste or irritate buccal mucous membrane.
These foods should be avoided.
2. ACUTE MYELOGENOUS LEUKAEMA
AML is a disease of the pluripotent myeloid stem cell. The cause of AML is unknown. It
occurs at any age, but occurs most often at adolescence and after the age 55 years. Peak
incidence is between 60-70 years of age.
Pathophysiology
The disease arises from a single myeloid stem cell and is characterized by the development of
immature myeloblasts in the bone marrow. While the clinical manifestations are as in ALL.
Management
 Treatment includes the use of Cytarabine, 6-thioquanine, and doxorubicin or
daunomycin.
 Treated patients MST is in 2 to 3 years. In the untreated or patient unresponsive to
therapy the MST is 2 to 3 months. Some studies show bone marrow transplantation
may benefit the clients.
 The patients and family should be instructed to avoid sources of potential infection.
Signs of potential infections should be recognized and reported to health care
provider.
 Precaution to minimize bleeding should also be emphasized (soft bristled tooth brush
and electric razor).
 The patient should be instructed to avoid possible injury or trauma (e.e blow nose
gently, avoid constipation).
 Dietary instruction should include the basics of nutritionally adequate diet,
particularly high protein and high fiber foods. Adequate amounts of fluids (2000 to
3000mls per day).
 The patient should be instructed about medication, effects, side effects and nursing
measures.
3. CHRONIC LYMPHOCYTIC LEUKAEMIA (CLL)
The incidence of CLL increases with ages and is rare under the age of 35 years. It is common
in men than women.
Pathophysiology
CLL is a form of neoplasm which is activated by lymphocytes. The cells which
morphologically resemble mature, small lymphocytes of the peripheral blood, accumulates in
the bone marrow, blood, lymph nodes and spleen in large number. CLL is characterized by
proliferation of small, abnormal, mature B lymphocytes, often leading to decrease synthesis
of immunoglobulin and depressed body antibody response. The accumulation of abnormal
lymphocytes begins in the lymph nodes and then spreads to other lymphatic tissues and the
spleen. The number of mature lymphocytes in peripheral blood smear and bone marrow are
greatly increased.
MANAGEMENT
  The MST of person with CLL is 4.5 to 5.5 years. As a general rule, persons are
treated only when symptoms, particularly anaemia, thrombocytopaenia, or enlarged
lymph node or spleen appear.
 Chemotherapeutic agents used in the treatment of CLL are most often one of the
alkylating agents, such as chlorambucil and the glucocorticoids. Although no
treatment is curative, remission may be induced by chemotherapeutics or radiation of
the thymus, spleen or entire body.
 Patient and family education is that described for AML.
4. CHRONIC MYELOGENOUS LEUKAEMIA (CML)
Occurs between 25 to 60 years of age. Its peak incidence is around 45 years of age.
Aetiology
The exact cause is not known. However, benzene exposure and high doses of radiation have
been associated with its development.
Philadelpia chromosome (translocation of chromosome 22 and 9) is identified in person
diagnosed with CML.
Pathophysiology
The primary defect in CML is abnormal cell leading to uncontrolled proliferation of the
granulocytic cells. As a result, proliferation, the number of circulating granulocytes increases
sharply.
Clinical Manifestation
There are no definitive symptoms in the disease. The Classic symptoms of chronic types of
leukaemia also exist in CML. These include fatigue, weakness, fever, sternal tenderness,
weight loss, joint pain, massive splenomegaly and increase in sweating.
CML commonly changes from a chronic indolent phase into a fulminant neoplastic process
sometimes indistinguishable from acute leukaemia.
The accelerated phase of the disease (blostic phase) is characterized by increasing of
granulocytes in the peripheral blood. There is a corresponding anemia and
thrombocytopaenia. Fever and adenopathy may also develop.
Management
 The goal of therapy of CML is to control proliferation of WBC. The commonly used
drugs are hydroxyurae and busulfan (monitor of WBC count needed with therapy).
 Once CML is converted into blastphase of disease, anthracyclines and cytocisine
arabinocyde have been used.
 The only potential curative therapy of CML is the bone marrow transplant.
 Nursing intervention of leukaemia patients include taking measures to prevent
infection, promoting safety, providing oral hygiene, preventing fatigue, promoting
effective coping as well as patient and family education regarding disease process;
oral care, medications and follow-up care.