Leukemia: Nursing process (ADPIE)

Taylor Oscar is a 64-year-old man who presents to the clinic with a three-week history of extreme fatigue, bruising, and flu-like symptoms.

Laboratory findings reveal a white blood cell count of 18,000 per cubic milliliter with 40% blasts, hemoglobin 12.6. Per deciliter and platelets 112,000 per cubic millimeter, a bone marrow biopsy and aspirate is performed which confirms a diagnosis of acute myeloid leukemia or AML.

Taylor is emergently admitted to the hematology oncology unit to begin treatment for AM. Leukemia refers to a group of cancers that can occur when there's uncontrolled proliferation of non-functional white blood cells or WBCs in the bone marrow.

This differentiates leukemias from lymphomas, which can also arise from white blood cells, but they typically form solid tumors in lymphatic tissue such as lymph nodes, thymus, or spleen.

Leukemias are grouped by how quickly the disease develops. Acute leukemia develops very quickly, over days to weeks, so the white blood cells don't mature at all and usually remain in the earlier blast form.

On the other hand, chronic leukemia develops slowly over many months or years, so the non-functional white blood cells have time to mature partially.

Now leukemias can be further grouped based on the cell type involved. Myeloid leukemias are caused by proliferation of cells from the myeloid cell line.

Such as monocytes or granulocytes, which include eosinophils, basophils, and neutrophils. On the other hand, lymphoid leukemias are caused by the proliferation of cells from the lymphoid line, which includes B and T cells.

So overall there's acute myeloid leukemia or AML, and acute lymphoblastic leukemia or ALL, as well as chronic myeloid leukemia or CML, and chronic lymphocytic leukemia or CLL.

Now, leukemias are thought to be caused by mutations in the precursor blood cells in the bone marrow, leading to uncontrolled proliferation.

There are certain risk factors that have been identified for developing these mutations. These include exposure to ionizing radiation, previous chemotherapy, smoking, and exposure to chemicals such as benzene.

Other risk factors include a history of antiseic hematologic disorders, including myelodysplastic syndromes and pre-existing genetic conditions such as Fanconi anemia, Bloom syndrome, xeroderma pigmentosum, Down syndrome, and Lee Fraumin syndrome.

Another risk factor is age, since ALL is more common in children, while AML and chronic leukemias are more common in adults.

Finally, leukemias are slightly more common among biological males than biological females. Clients with leukemia typically present with symptoms like weight loss, weakness, night sweats, and unexplained fever.

As the non-functional white blood cells keep proliferating in the bone marrow, they take up a lot of space, so the other normal blood cells growing in the bone marrow get crowded out.

Ultimately, this results in complications like cytopenia, including anemia, thrombocytopenia, and leukopenia. As a consequence, symptoms of leukemia can include pallor and fatigue because of the anemia, easier bleeding, bruising, and petechia because of the thrombocytopenia, and frequent infections because of the leukopenia.

Other symptoms may include pain and tenderness in the bones due to an increased white blood cell production. In addition, these white blood cells may start to spill out into the blood.

Some of them can deposit in organs and tissues throughout the body, such as the liver and spleen, causing hepatosplenomegaly, which often causes a feeling of abdominal fullness, or the lymph nodes causing lymphadenopathy, which often causes mild but localized pain in the lymph nodes.

The diagnosis of leukemia usually starts with history and physical examination followed by a complete blood count or CBC which generally reveals increased white blood cells along with cytopenia.

Additionally, a peripheral blood smear may show increased blast cells, myeloblasts in case of AML, and lymphoblasts in case of ALL.

This is usually followed up by a bone marrow biopsy, which also shows an increase in blast cells. In acute leukemia, the percentage of blast cells in the bone marrow goes up from their normal value of 1 to 2% to greater than 20%.

Treatment is mainly aimed at reducing the number of blast cells, which can allow the other blood cells to develop normally, and it generally consists of three chemotherapy phases induction, which is aimed at inducing remission.

Consolidation aimed at eliminating any remaining leukemic cells. And maintenance aimed at preventing relapse.

The choice of treatment will depend on the client's age and medical fitness, which generally means those with no severe comorbid conditions, so they can tolerate treatment with intensive chemotherapy.

On the other hand, medically unfit but not frail clients are typically treated with low intensity chemotherapy. Finally, frail clients wouldn't tolerate chemotherapy, so they're treated with supportive care to help improve their quality of life.

Other treatments for leukemia include radiation therapy, which can be used to destroy cancer cells if they invade the brain and spine, hematopoietic stem cell transplantation, and immunotherapy.

Let's get back to assess our client Taylor. Since being admitted, he has had a central venous access device, or CVAD inserted for his induction treatment, which he is scheduled to start tomorrow morning.

After entering his room, you ask him how he is doing, and he says he is feeling confused and anxious about his recent diagnosis and beginning treatment so quickly.

He appears overwhelmed and is not sure when he will be able to go home. Upon examination, his lungs are clear to auscultation.

He says he isn't experiencing any shortness of breath at rest. However, states that he has been so exhausted during the last few weeks that he has not been able to maintain his usual level of activity.

Often he feels like he can't catch his breath when he is up moving for more than a few minutes. His abdomen is soft and bowel sounds are present in all four quadrants.

He has noticeable bruising on his legs bilaterally. His vital signs are temporal temperature 98.6 °F or 37 °C, heart rate 95 BPM and regular, respirations 20 breaths per minute, BP 115/72 millimeters of mercury, oxygen saturation 94% on room air, and pain zero out of 10.

You document your assessment findings prior to leaving the room. Based on the assessment data you have collected, your nursing diagnoses include risk for infection related to altered immune function, risk for bleeding related to decreased platelets, fatigue related to diminished oxygen-carrying capacity of the blood, deficient knowledge and anxiety related to new diagnosis and change in health status.

OK. Now that you've established nursing diagnoses, you plan with Taylor and his healthcare team to achieve some important goals for care.

During treatment, Taylor will continue to remain afebrile, and he will be able to identify actions to reduce his risk of infection.

He will understand his increased risk for bleeding, verbalize important measures he should implement to prevent bleeding, and be able to identify the signs of bleeding that need to be reported immediately.

Taylor will report decreased levels of fatigue and verbalize how he can use energy conserving techniques. He will demonstrate an understanding of his diagnosis, treatment regimen, and required self-care to prevent potential complications.

Prior to the end of your shift, Taylor's anxiety will be reduced to a manageable level, as demonstrated through him asking questions, examining his fears, and sharing his feelings about his new diagnosis.

Now that you've identified goals, you implement the plan of care. You carefully monitor Taylor for any signs of infection, including fever, chills, flushed skin, tachycardia, and hypotension.

You also monitor his CVAD site for any drainage, edema, and redness, and you explain the importance of meticulous hand washing and frequent oral care to prevent infection.

You also let him know that he should wear a mask if he is leaving his room. Avoid any crowded places such as the hospital cafeteria, and avoid individuals who are sick.

Since his decreased platelet level increases his risk for bleeding, Taylor will be monitored closely for signs of serious bleeding such as headache with change in responsiveness, blurred vision, hemoptysis, hematemesis, melina, hypotension, tachycardia, and dizziness.

You teach him about the importance of bleeding precautions such as using an electric razor while shaving, avoiding straining with bowel movements, using a soft bristled toothbrush, and avoiding forceful coughing or blowing his nose.

Because his platelet level will continue to decrease with chemotherapy, you inform him that he will receive platelet transfusions if his platelets drop too low or if he experiences any active bleeding.

Next, you reinforce the information provided by the oncologist about his diagnosis, course of treatment, and the effects of chemotherapy.

You explain that the chemotherapy will reduce his blood counts, which can further decrease his energy levels. You emphasize the importance of energy conservation strategies during and after his treatment.

Strategies such as sitting instead of standing while showering, asking for assistance when needed, and balancing activity with rest will help him decrease the amount of energy used while his blood counts are low.

However, you discuss that during certain times in his treatment, he may require transfusions of blood products if he is feeling very short of breath or if his energy levels drop too low.

Finally, you emphasize the importance of expressing his feelings and thoughts about his recent diagnosis if and when he is ready.

You establish an open and safe environment by encouraging him to ask questions and express his fears about treatment so you can provide additional support as needed.

To ensure the continuation of education and supportive care, you document in his chart the specific teaching and support that you provided so that this process can be continued and reinforced throughout his hospitalization.

Throughout your shift, you will notify the oncologist immediately if you assess any signs of infection, bleeding, or unexpected fatigue.

It is near the end of your shift, and it is time to evaluate and see how Taylor is doing so far. His latest vital signs are temporal temperature 98.6 °F or 37 °C, heart rate 80 BPM, respiratory rate 20 breaths per minute, BP 120/80 millimeters of mercury, oxygen saturation 94% on room air, pain 0 out of 10.

He has not displayed any signs or symptoms of infection or bleeding. Taylor is able to verbalize his understanding of AML, his treatment regimen, and the importance of implementing protective measures to decrease his risk of infection and bleeding.

He remains anxious about starting treatment but appears more relaxed after being able to communicate his fears and feelings and to ask questions.

Although he is still feeling fatigued, he understands the energy conserving strategies and the importance of implementing these during and after treatment.

To meet Taylor's medical, spiritual, and psychological needs, specialized holistic nursing care will continue throughout his treatment.

All right, as a quick recap, leukemia is a group of malignancies with uncontrolled production of immature or non-functional white blood cells in the bone marrow.

As a result, the bone marrow becomes overcrowded with leukemic cells, which reduces the number of normal, healthy blood cells such as red blood cells and platelets, and major symptoms of leukemia are related to anemia, thrombocytopenia, and neutropenia.

Your assessment revealed that Taylor was experiencing fatigue and shortness of breath on exertion, bruising on his legs, and anxiety related to his recent diagnosis of AML.

Your nursing diagnoses were risk for infection, risk for bleeding, fatigue, deficient knowledge, and anxiety. The goals you identified when planning care for Taylor included reducing risk of infection, decreasing levels of fatigue, reducing risk of bleeding, understanding his recent diagnosis and treatment plan, and reducing his anxiety.

Along with the other members of the healthcare team, you work to implement actions that achieve the goals of Taylor's plan of care.

Throughout his treatment, the healthcare team will continue to evaluate if his goals are being met.