How Leukemia Is Diagnosed?

Leukemia (Greek leukos means white, and haima means blood) is a type of cancer of the blood or bone marrow characterized by an abnormal increase of immature white blood cells called blasts.

Leukemia is acute when WBCs proliferate so rapidly that they lose the ability to regulate cell division and do not differentiate into mature cells.

In chronic forms of leukemia, the disease develops gradually. The type of leukemia is based on the predominant cell line that is affected.

Classification of Leukemia

Clinically and pathologically, leukemia is subdivided into a variety of large groups. The first division is between its acute and chronic forms:

• Acute leukemia is characterized by a rapid increase in the numbers of immature blood cells. Crowding due to such cells makes the bone marrow unable to produce healthy blood cells. Immediate treatment is required in acute leukemia due to the rapid progression and accumulation of the malignant cells, which then spill over into the bloodstream and spread to other organs of the body. Acute forms of leukemia are the most common forms of leukemia in children.
• Chronic leukemia is characterized by the excessive build-up of relatively mature, but still abnormal, white blood cells. Typically taking months or years to progress, the cells are produced at a much higher rate than normal, resulting in many abnormal white blood cells. Whereas acute leukemia must be treated immediately, chronic forms are sometimes monitored for some time before treatment to ensure maximum effectiveness of therapy. Chronic leukemia mostly occurs in older people, but can theoretically occur in any age group.

Additionally, the diseases are subdivided according to which kind of blood cell is affected. This split divides leukemias into lymphoblastic or lymphocytic leukemias and myeloid or myelogenous leukemias.

• In lymphoblastic or lymphocytic leukemias the cancerous change takes place in a type of marrow cell that normally goes on to form lymphocytes, which are infection-fighting immune system cells. Most lymphocytic leukemias involve a specific subtype of lymphocyte, the B cell.
• In myeloid or myelogenous leukemias, the cancerous change takes place in a type of marrow cell that normally goes on to form red blood cells, some other types of white cells and platelets.

Combining these two classifications provides a total of four main categories. Within each of these four main categories, there are typically several subcategories. Finally, some rarer types are usually considered to be outside of this classification scheme.

• Acute lymphoblastic leukemia (ALL) is the most common type of leukemia in young children. This disease also affects adults especially those ages 65 and older. Standard treatments involve chemotherapy and radiotherapy
• Chronic lymphocytic leukemia (CLL) most often affects adults over the age of 55. It sometimes occurs in younger adults, but it almost never affects children. Two-thirds of the affected people are men.
• Acute myelogenous leukemia (AML) occurs more commonly in adults than in children, and more commonly in men than women. AML is treated with chemotherapy. The five-year survival rate is 40 %.
• Chronic myelogenous leukemia (CML) occurs mainly in adults. A very small number of children also develop this disease.

Risk Factors

No one knows the exact causes of leukemia. However, research shows that certain risk factors increase the chance that a person will get this disease.

The risk factors may be different for the different types of leukemia:

• 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.
• Atomic bomb explosions: Very high levels of radiation have been caused by atomic bomb explosions (such as those in Japan during World War lI). People, especially children, who survive atomic bomb explosions, are at increased risk of leukemia.
• Radiation therapy: Another source of exposure to high levels of radiation is medical treatment for cancer and other conditions. Radiation therapy can increase the risk of leukemia.
• Diagnostic x-rays: Dental x-rays and other diagnostic x-rays (such as CT scans) expose people to much lower levels of radiation. It’s not known yet whether this low level of radiation to children or adults is linked to leukemia. Researchers are studying whether having many x-rays may increase the risk of leukemia. They are also studying whether CT scans during childhood are linked with an increased risk of developing leukemia.
• Smoking: Smoking cigarettes increases the risk of acute myeloid leukemia.
• Benzene: Exposure to benzene in the workplace can cause acute myeloid leukemia. It may also cause chronic myeloid leukemia or acute lymphocytic leukemia. Benzene is used widely in the chemical industry. It’s also found in cigarette smoke and gasoline
• Chemotherapy: Cancer patients treated with certain types of cancer-fighting drugs sometimes later get acute myeloid leukemia or acute lymphocytic leukemia. For example, being treated with drugs known as alkylating agents or topoisomerase inhibitors is linked with a small chance of later developing acute leukemia.
• Down syndrome and certain other inherited diseases: Down syndrome and certain other inherited diseases increase the risk of developing acute leukemia.
• Myelodysplastic syndrome and certain other blood disorders: People with certain blood disorders are at increased risk of acute myeloid leukemia.
• Human T-cell leukemia virus type I (HTLV- l): People with HTL-l infection are at increased risk of a rare type of leukemia known as adult T-cell leukemia. Although the HTLV-I virus may cause this rare disease adult T-cell leukemia and other types of leukemia are not contagious.
• Family history of leukemia: It’s rare for more than one person in a family to have leukemia. When it does happen, it’s most likely to involve chronic lymphocytic leukemia. However, only a few people with chronic lymphocytic leukemia have a father, mother brother, sister, or child who also has the disease.

Having one or more risk factors does not mean that a person will get leukemia. Most people who have risk factors never develop the disease.

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Symptoms

Common symptoms of chronic or acute leukemia may include:

• Swollen lymph nodes that usually don’t hurt (especially lymph nodes in the neck or armpit)
• Fevers or night sweats
• Frequent infections
• Feeling weak or tired
• Bleeding and bruising easily (bleeding gums purplish patches in the skin, or tiny red spots under the skin)
• Swelling or discomfort in the abdomen (from a swollen spleen or liver)
• Weight loss for no known reason
• Pain in the bones or joints

Most often, these symptoms are not due to cancer. An infection or other health problems may also cause these symptoms.

Diagnosis

• Physical exam: Checks for swollen lymph nodes, spleen, or liver
• 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.
• Biopsy: A biopsy is the only sure way to diagnose leukemia
• Bone marrow aspiration: The doctor uses a thick, hollow needle to remove samples of bone marrow.
• Bone marrow biopsy: The doctor uses a very thick, hollow needle to remove a small piece of bone and bone marrow
• Other Tests
  • Cytogenetics: The lab looks at the chromosomes of cells from samples of blood, bone marrow, or lymph nodes. If abnormal chromosomes are found, the test can show what type of leukemia it is. For example, people with CML have an abnormal chromosome called the Philadelphia chromosome.
  • Spinal tap: Check CSF fluid for leukemia cells or other signs of problems
  • Chest x-ray: An x-ray can show swollen lymph nodes or other signs of disease in your chest.

Treatment of leukemia

• Supportive treatment: includes the administration of blood, antibiotics, sedative may also be given to make the child comfortable
• Chemotherapy: specific therapy involves the use of chemotherapeutic agents (cytotoxic drugs) which produce certain side effects when used
• Corticosteroids: produce Cushing’s syndrome including moon face, fluid retention, and hypertension, personality changes when heavy dose or prolonged therapy is given.
• Methotrexate: It’s used also ‘produce a sign of toxicity including oral and gastrointestinal ulceration, hemorrhage, chills, fever hematologic depression, skin reaction such as rash, acne, diarrhea and occasionally alopecia may also be seen
• 6-Mercaptopurine:-The chief manifestation of toxicity of this drug is interference with hematopoiesis and myelotoxicity.
• Vincristine: The drug may produce sensory and neuromuscular toxicity as well as constipation and alopecia
• Cyclophosphamide: May produce nausea, vomiting, anorexia, depression of bone marrow, myelotoxicity, alopecia may also occur.
• Daunorubicin: Its use causes bone marrow damage and complication involving the cardiopulmonary system, gastrointestinal disturbance, skin rash, and hair loss.
• L-asparaginase: The toxic effects include potentially dangerous blood coagulation and liver tissue abnormality, allergic reaction of the anaphylactic type may occur.
• Cesar: The predominant toxic effect is marrow suppression and may also produce nausea and vomiting.

Nursing diagnosis/care of patients with leukemia

Based on the assessment data, major nursing diagnoses for the patient with acute leukemia may include:

• The risk for infection and bleeding
• The risk for impaired skin integrity related to toxic effects of chemotherapy, alteration in nutrition, and impaired mobility
• Impaired gas exchange
• Impaired mucous membranes due to changes in the epithelial lining of the gastrointestinal tract from chemotherapy or prolonged use of antimicrobial medications.
• Imbalanced nutrition, less than body requirements, related to hypermetabolic state anorexia, Mucositis, pain, and nausea.
• Acute pain and discomfort related to mucositis, WBC infiltration of systemic tissues, fever, and infection
• Hyperthermia related to tumor lysis and infection
• Fatigue and activity intolerance related to anemia and infection
• Impaired physical mobility due to anemia and protective isolation
• The risk for excess fluid volume related to renal dysfunction, hypoproteinaemia, need for multiple intravenous medications and blood products
• Diarrhea due to altered gastrointestinal flora, mucosal denudation
• The risk for deficient fluid volume related to the potential for diarrhea, bleeding, infection, and increased metabolic rate
• Self-care deficit due to fatigue, malaise, and protective isolation
• Anxiety due to knowledge deficit and uncertain future
• Disturbed body image related to change in appearance, function, and roles
• Grieving related to anticipatory loss and altered role functioning
• Potential for spiritual distress
• Deficient knowledge about the disease process, self-care measures

Nursing Intervention

1. Prevent complications

• Avoid aspirin and aspirin-containing medications or other medications known to inhibit platelet function, if possible.
• Do not give intramuscular injections.
• Do not insert indwelling catheters.
• Take no rectal temperatures; do not give suppositories enemas.
• Use stool softeners, oral laxatives to prevent constipation.
• Use smallest possible needles when performing venipuncture
• Apply pressure to sites for 5 min or until the bleeding has stopped.
• Permit no flossing of teeth and no commercial mouthwashes.
• Use an only soft-bristled toothbrush for mouth care
• Use only toothpaste for mouth care if the platelet count is <10,000/mm3, or if gums bleed.
• Lubricate lips with water-soluble lubricant every 2 hr while awake.
• Avoid suctioning if at all possible; if unavoidable, use only gentle suctioning
• Discourage vigorous coughing or blowing of the nose.
• Use an only electric razor for shaving.
• Pad side rails as needed.
• Prevent falls by ambulating with the patient as necessary

2. Control Bleeding

• Apply direct pressure.
• For epistaxis, position patient in high Fowler’s position; apply an ice pack to the back of the neck and direct pressure to the nose.
• Notify physicians for prolonged bleeding (e.g. unable to stop within 10 min).
• Administer platelets fresh frozen plasma packed red blood cells, as prescribed.

3. Managing Mucositis

• Although the emphasis is placed on the oral mucosa, it is important to realize that the entire gastrointestinal mucosa can be altered, not only by the effects of chemotherapy but also from prolonged administration of antibiotics.
• Assessment of the oral mucosa should be done which includes: the palate, buccal mucosa, tongue, gums, lips, oropharynx, and the area under the tongue. In addition to identifying and describing lesions, the color and moisture of the mucosa should be noted.
• Oral hygiene is very important to diminish the bacteria within the mouth, maintain moisture and provide comfort.
• Soft-bristled toothbrushes should be used until the neutrophils and platelet counts become very low; at that time, sponge-tipped applicators should be substituted. Simple rinses with saline (or saline and baking soda) solutions are inexpensive but effective in cleaning and moistening the oral mucosa. Because the risk of yeast or fungal infection in the mouth is great, other medications are often prescribed, such as chlorhexidine rinses (eg, Peridex) or clotrimazole troches (e.g., Mycelex).
• Women are instructed to cleanse the perineum from front to back. Sitz baths are a comfortable method of cleansing; the perineal-anal region and buttocks must be carefully dried afterward to minimize the chance of excoriation.
• Stool softeners should be used to increase the moisture of bowel movements; however, the stool texture must be monitored so that the softeners can be decreased or stopped if the stool becomes too loose.

4. Improving nutritional intake: The disease process can increase, and sepses further increase, the patient’s metabolic rate and nutritional requirements.

• Nutritional intake is often reduced because of pain and discomfort associated with stomatitis. Mouth care before and after meals and administration of analgesics before eating can help increase intake. If oral anesthetics are used, the patient must be warned to chew with extreme care to avoid inadvertently biting the tongue or buccal mucosa.
• Small, frequent feedings of foods that are soft in texture and moderate in temperature may be better tolerated.
• Parenteral nutrition is often required to maintain adequate nutrition

5. Easing pain and discomfort: Recurrent fevers are common in acute leukemia; at times, they are accompanied by shaking chills, which can be severe (rigors). Myalgia and arthralgia can result.

• Acetaminophen is typically given to decrease fever, but it does so by increasing diaphoresis.
• Sponging with cool water may be useful, but cold water or ice packs should be avoided because the heat cannot dissipate from constricted blood vessels.
• Bedclothes need frequent changing as well
• The gentle back and shoulder massage may provide comfort.
• Stomatitis can also cause significant discomfort. In addition to oral hygiene practices, patient-controlled analgesia can be effective in controlling the pain.

6. Decreasing fatigue and deconditioning: Fatigue is a common and oppressive problem. Nursing interventions should focus on assisting the patient to establish a balance between activity and rest. Patients with acute leukemia need to maintain some physical activity and exercise to prevent the deconditioning that results from inactivity. At a minimum, patients should be encouraged to sit up in a chair while awake rather than staying in bed; even this simple activity can improve the patient’s tidal volume and enhance circulation. Physical therapy can also be beneficial.
7. Maintaining fluid and electrolyte balance: Febrile episodes, bleeding, and inadequate or overly aggressive fluid replacement can alter the patient’s fluid status. Similarly, persistent diarrhea, vomiting, and long-term use of certain antimicrobial agents can cause significant deficits in electrolytes.

• Intake and output need to be measured accurately, and daily weights should also be monitored.
• The patient should be assessed for signs of dehydration as well as fluid overload, with particular attention to pulmonary status and the development of dependent edema.
• Laboratory test results, particularly electrolytes, blood urea nitrogen, creatinine, and hematocrit, should be monitored and compared with previous results
• Replacement of electrolytes, particularly potassium and magnesium, is commonly required. Patients receiving amphotericin or certain antibiotics are at increased risk for electrolyte depletion.

8. Improving self-care: Because hygiene measures are so important in this patient population, they must be performed by the nurse when the patient cannot do so

• However, the patient should be encouraged to do as much as possible, to preserve mobility and function as well as self-esteem
• Patients may have negative feelings, even disgust that they can no longer care for themselves. Empathetic listening is helpful, as is realistic reassurance that these deficits are temporary

9. Managing anxiety and grief: Being diagnosed with acute leukemia can be extremely frightening.

• Providing emotional support and discussing the uncertain future is crucial. The nurse also needs to assess how much information patients want to have regarding the illness, its treatment, and potential complications.
• Many patients become depressed and begin to grieve for the losses they feel, such as normal family functioning, professional roles and responsibilities, and social roles, as well as physical functioning. Nurses can assist patients to identify the source of the grief and encourage them to allow time to adjust to the major life changes produced by the illness
• Role restructuring, in both family and professional life, may be required. Again, when possible, permitting patients to identify options and to take time making significant decisions regarding such restructuring is helpful.
• Discharge from the hospital can also provoke anxiety. Although most patients are extremely eager to go home, they may lack confidence in their ability to manage potential complications and to resume their normal activity.
• Close communication between nurses across care settings can reassure patients that they will not be abandoned.

10. Encouraging spiritual well-being: Because acute leukemia is a serious, potentially life-threatening illness, the nurse may offer support to enhance the patient’s spiritual well being. The patient’s spiritual and religious practices should be assessed and pastoral services offered. Throughout the patient’s illness, it is important that the nurse assists the patient to maintain hope. However, that hope should be realistic and will certainly change over the course of the illness. For example, the patient may initially hope to be cured, but with repeated relapses and a change to terminal care, the same patient may hope for a quiet, dignified death.

Summary of responsibility of the nurse

The nursing care of a child having leukemia is based not only on the sign, symptom, and complication of the disease itself but also on the side effect of the drug used in the treatment.

• Protection from infection and treatment of any infection.
• Since the child who has leukemia also has anemia, he gets tired easily and needs a frequent rest period. He should have well-balanced meals, adequate fluid intake is important.
• Since the child has low platelet count he should be observed carefully for hemorrhage.
• Good oral hygiene is important.
• The child is observed carefully for any indication of CNS involvement such as changes in his behavior, nausea, vomiting irritability and headache.
• The child must be observed for convulsion and any toxic manifestation of the drug used.
• Bone marrow aspirate is necessary for the diagnosis and treatment of leukemia. Bone marrow is obtained from the sternum or iliac crest.
• The child must be given physical and emotional support.
• When the critically ill child lapses into unconsciousness, the nurse must remain with the parents at his bedside so that they know that everything possible is being done for his comfort.