complete information about the cancer condition that is leukemia - introduction, definition, etiology and causes, pathophysiology ,types, clinical manifestations, diagnosis, nursing management, medical management, nursing research .

1. LEUKEMIA
SUBMITTED TO:
mRS. MAMTA TOPPO
ASSOCIATE PROFESSOr
College of nursing
Rims , ranchi
SUBMITTED BY:
PRATIBHA KUMARI
ROLL NO.-18
BASIC B.SC NURSING 3rd YEAR

2. SPECIFIC OBJECTIVES
Introduction of Leukemia.
Definition of Leukemia.
Incidence of Leukemia.
Etiology & Risk factors of
Leukemia.
Pathophysiology of
Leukemia.
Types of Leukemia.
Clinical manifestations of
Leukemia.
Diagnostic evaluation of
Leukemia.
New Research
Summary
Evaluation
Reference
Bibliography

3. INTRODUCTION
i. Cancer of hematopoietic system are disorders that
result from proliferation of malignant cells.
ii. Malignant cells are originated in bone marrow, thymus, and
lymphatic tissue.
iii. Blood cells that originate in bone marrow are called
hematopoietic cells.
iv. Blood cells that originate in lymph are called lymphoid
cells.
v. Leukemia (Cancer of Bone marrow)
vi. Lymphoma (Cancer of lymphoid tissue)

4. DEFINITION
• Leukemia is a malignant disease of the blood-
forming organs.
• Leukemia is a malignant progressive disease in which
the bone marrow & other blood forming organs
produce increased no. of immature / abnormal
leucocytes, these suppresses the production of normal
blood cells, leading to anemia & other symptoms.

6. INCIDENCE (in India)
• About 3-4 per 100,000 population.
• These people account for 30% to 52% of all childhood cancers in males,
and 19% to 52% in females.

7. ETIOLOGY AND RISK FACTORS
• The exact cause is unknown.
• Several factors are associated with leukemia include:
1. Genetic factor
-A high incidence of acute leukemia & chronic lymphocytic leukemia is reported in
certain families.

8. - Hereditary abnormalities associated with an increased incidence of leukemia are
Down's syndrome, Fanconi's aplastic anemia, Trisomy of 13 (Patau's syndrome),
etc.
- Identical twins, fraternal twins, and siblings of children with leukemia are also
at increased risk.

9. 2. Over-exposure to ionizing radiation and chemicals:
Can become a major risk factor for development of leukemia, with disease
developing years after initial exposure.
Alkylating agents used to treat other cancers, especially in combination with
radiation therapy, increase a person's risk of leukemia.
Workers exposed to chemical agents, such as benzene (an aromatic hydrocarbon),
are at a much higher risk.

10. 3. Congenital abnormalities:
- Down's syndrome.
4. The presence of:
-Primary immunodeficiency
-Infection with the Human T-cell Leukemia Virus Type-1
(HTLV-1).

12. PATHOPHYSIOLOGY
The pathophysiology of leukemia involves:
• Abnormal proliferation of leukocytes
• Failure of leukocytes to mature
• Metabolic complications
• Abnormal leukocytes cannot perform the primary function
• Abnormal cells crowd the bone marrow, lymph nodes, and spleen
• Infection and bleeding are two common perils

14. TYPES
There are 4 major types on the basis of acute versus chronic, the term acute
and chronic refers to cell maturity and nature of disease onset:
i. Acute lymphocytic leukemia.
ii. Acute myelogenous leukemia.
iii. Chronic lymphocytic leukemia.
iv. Chronic myelogenous leukemia.

15.  Primary diff. b/w the four types is the rate of progression and
where the cancer develops.
 Chronic leukemia cells do not mature all the way, so they are not
as capable of defending against infections as normal
lymphocytes.
 Acute leukemia cells begin to replicate before any immune
functions have developed.

16. 1. Acute lymphocytic leukemia:
Most common type of leukemia in children, andaccounts for 15% in adults.
 In this type , immature lymphocytes proliferatein bone marrow. most are of B-
cell origin.
Age of onset:
- Before 14 year of age
. - peak incidence in b/w 2-9 years of age,
- and in older adults

17.  Clinical manifestations:
- Fever, pale skin, bleeding, anorexia, fatigue and weakness.
- Bone , joint and abdominal pain.
- Generalized lymphadenopathy, infection, weight loss.
- Hepatomegaly mouth sores, splenomegaly, headache.
- Increased ICP (nausea, vomiting, lethargy, cranial nerve dysfunction)

18. Diagnostic evaluation:
- Low RBC count, Hb, low platelet count.
- Low, or high WBC count.
- Transverse lines of rarefaction at ends ofmetaphysis of long
bones on X-rays.
- Hyper cellular bone
- marrow with lymphoblast.
- Lymphoblast also possible in CSF.
- Presence of Philadelphia chromosomes (20-25% cases).

19. 2. ACUTE MYELOGENOUS
LEUKEMIA:
This type represents only 1/4th of all leukemias, in which 85% of this type
in adults.
It is characterized by uncontrolled proliferation of myeloblasts, precursors
of granulocytes.
There is hyperplasia of bone marrow.

20. AGE OF ONSET:
- Its onset is often abrupt & dramatic, a patient may have serious
infections and abnormal bleeding from the onset of disease.
- Increase in incidence with advancing age, peakincidence b/w 60
and 70 year of age.

21. CLINICAL MANIFESTATIONS
- Fatigue
- Weakness
- Headache
- Mouth anemia, bleeding, fever, infection ,sores, sternal
tenderness
- Gingival hyperplasia, minimal hepato-splenomegaly &
lymphadenopathy

22. Diagnostic evaluation:
- Low RBC count, Hb,
- Low platelet count,
- low to high WBC count with myeloblasts
- High LDH, greatly hypercellular bone marrow with myeloblasts.

23. 3. CHRONIC LYMPHOCYTIC
LEUKEMIA:
It is most common type in adults.
It is characterized by production and accumulation of functionally inactive
but long. lived, small, mature-appearing lymphocytes.
The type of lymphocytes involved is usually B -cell.
The lymphocytes infiltrate the organ.

24. • Lymphadenopathy is present throughout the body, and there is an
increased incidence of infection because of T-cell deficiencies or
hypogammaglobulinemia.
• Pressure on nerves from enlarged lymph nodes cause pain and
even paralysis
• . • Onset:
- 50-70 years of age, rare below 30 year of age.

25. • . Clinical manifestations:
- No symptoms frequently.
- Disease is often detected during examination for unrelated
conditions, chronic fatigue, anorexia.
- Splenomegaly & lymphadenopathy.
- Hepatomegaly, may progress to fever, night sweats, weight loss.

26. • Diagnostic evaluation:
• - Mild anemia and thrombocytopenia with diseaseprogression; total
WBC count >100,000/micro L.
• - Hemolytic anemia (4-11%).
• - Thrombocytopenia purpura (2-4%).
• - Hypogammaglobulinemia.

27. 4.CHRONIC MYELOGENOUS
LEUKEMIA
It is caused by excessive development of mature neoplastic
granulocytes in the bone marrow. The excess neoplastic granulocytes move
into peripheral blood in massive no. and ultimately infiltrate the liver &
spleen . These cells contain a distinctive cytogenetic abnormality, the
Philadelphia chromosomes, which serves as a disease marker and results
from translocation of genetic material between chromosomes 9 and 22.

28. • . Age of onset:
- 25 to 60 year of age, peak incidence around 45 year of age.
• Clinical manifestations:
- No symptoms are seen earlier.
- Fatigue and weakness, fever, sternal tenderness, weight loss, joint
pain, pain in bone, massive splenomegaly, increase in sweating, to
60 year of age, peak incidence around 45 year of age.

29. • Diagnostic findings:
- Low RBC count, Hb, Hct.
- High platelet count early, lower count later.
- Presence of Philadelphia chromosomes in 90% Of patients.

30. CLINICAL MANIFESTATION
• Clinical features of leukemia relate to the problems caused by bone marrow
failure andformation of leukemic infiltrates
•As leukemia progresses:
- Fewer normal blood cells are produced
- Abnormal WSC continue to accumulate ( don'tgo through apoptosis)

31. • - The leukemic cells infiltrate the patient's organs, leading to
problems such as splenomegaly, hepatomegaly, lymphadenopathy,
bone pain, meningeal irritation and oral lesions.
• - Solid masses resulting from collection of leukemic cells called
chlormas can also occur.

33. DIAGNOSTIC EVALUATION
• A history collection.
• Physical examination.
• Peripheral blood evaluation ( WBC & platelets count)
• Bone marrow examination (sampling from hipbone).
• Lumbar puncture and CT scan are done to determine the presence of
leukemic cells outside of blood & bone marrow.

36. MANAGEMENT
• PHARMACOLOGICAL MANAGEMENT
It includes the chemotherapy, which is a major form of treatment for
leukemia. This drug treatment use chemicals to kill leukemia cells.
This can be a drug or a combination of drugs. these can be in form of pill or
IV injection.

37. • 1.For acute myelogenous leukemia:
Antitumor antibiotics anthracycline -:
- Daunorubicin,
- Doxorubicin,
- Idarubicin,
- Mitoxantrone.

38. • Podophyllotoxin:
- Etoposide.
• Retinoid:
- Tretinoin.
• bolitetabolite:
- Cytarabine,
- 6-thioguanine.

39. • Miscellaneous:
- Arsenic tri-oxide
• Combination of cytarabine and anti-tumor antibiotic.

40. • 2. For acute lymphocytic leukemia:
Anti-tumor antibiotics (anthracycline):
-Daunorubicin,
-Doxorubicin.
> Alkylating agents:
-Cyclophosphamide.

41. • Anti-metabolites:
-Cytarabine,
- 6-mercaptopurine,
-methotrexate
• Corticosteroids:
- Prednisolone,
- Dexamethasone.

42. • Mitotic inhibitors / Vinca alkaloids:
-Vincristine.
• Biologic / targeted therapy:
- Dasatinib.
• Miscellaneous:
- L- asparaginase.
- Pegaspargase.
• Other therapies:
- Cranial radiation,
- Intrathecal methotrexate or cytarabine

43. • 3. Chronic myelogenous leukemia:
> Biologic/targeted therapy:
- Imatinib,
- Dasatinib.
Miscellaneous:
- Hydroxyurea

44. • Combination chemotherapy including any of:
- Cytarabine,
- thioguanine,
-Daunorubicinn,
- Methotrexate
- Prednisone,
- Vincristine,
- L - asparaginase,
- Carmustineine,
- 6-mercaptopurine.

45. >Other therapies:
- Radiation (total body / spleen).

46. • 4. Chronic lymphocytic leukemia:
• > Alkylating agents:
- Chlorambucil,
- Cyclophosphamide.
. > Antimetabolites:
- Fludarabine
> Corticosteroid:
- Prednisone.

47. • > Biologic/ targeted therapy:
- Alemtuzumab,
- Rituximab.
• > Miscellaneous:
- Pentostatin.
• > Other herapies:
- Radiation (total body, lymph nodes, or spleen)

48. • SURGICAL MANAGEMENT:
1. For acute myelogenous leukemia:
✓Autologous or allogeneic hematopoietic stem cell transplant.
2. For acute lymphocytic leukemia:
✓ Allogeneic hematopoietic Stem cell transplant.

49. • 3. For chronic myelogenous leukemia:
✓ Hematopoietic cell transplant, interferon, leukapheresis.
• 4. For chronic lymphocytic leukemia:
✓ Splenectomy, allogeneic hematopoietic stem cell transplant.

50. • • NURSING MANAGEMENT:
>Assessment:
> Nursing diagnosis:
1.Ineffective protection / risk for infection related to neutropenia or
leukocytosis secondary to leukemia or treatment.
Intervention:
•Assessing client.
•handwashing techniques.
• Client isolation.

51. • Low bacteria diet (excluding fruits & vegetables).
• Daily bath with antibacterial soap.
• Maintain oral hygiene.
• Daily stool softeners (to reduce anal fissures).
• Perineal cleansing for every bowel movement.
• Avoid rectal suppositories & rectal thermometer.
• Temperature should be taken (oral, axilla, tympanic) every 4 hourly,
report if more than 100.5 °F or lower than 97.5°F ( because fever is only
the symptom in neutropenic client).

52. • 2. Decreased cardiac output related to thrombocytopenia
secondary to either leukemia or treatment.
• INTERVENTION:
• Institute bleeding precautions:
- Provide a soft toothbrush for oral hygiene
- Avoid commercial mouthwash containing alcohol.
- Avoid blowing or picking nose, straining at bowel movements,
douching or using tampons, using razorsduring neutropenic phase.

53. - Don't administer IM/SC inj.
- Do not insert rectal suppository.
- Avoid aspirin containing drugs.
- Avoid urinary catheterization, if needed then only lesser sized.
- Avoid mucosal trauma during suctioning.
- Remove all sharp objects around client.
- Use pressure reducing mattress, proper change the position
- Use only paper tape ,avoid strong adhesive (can cause skin
adhesions).

54. 3. Fatigue related to side effects of treatments, low haemoglobin
levels, pain, lack of sleep.
INTERVENTION:
• Assess for anemia.
• Assess for physical, mental and treatment related causes of fatigue.
• Encourage exercise to maintain strength.
• Allow for rest.

55. • 4. imbalanced nutrition less than body requirements related to
anorexia, pain or fatigue.
INTERVENTION:
• Administer anti-emetics. (before meal/ drinking).
• Administer local IV analgesics.
• Provide high Cho meals & oral supplements .Weight daily.
• If client can not tolerate oral foods for an extended period, begin
TPN, as ordered.
• Monitor intake.

56. • 5. Disturbed body image resulting from alopecia, weight loss and
fatigue.
Intervention:
• Before treatment, inform client about the potential for hair loss over
entire body.
•Encourage use of hats, etc as desired.
• Explain the temporary nature of alopecia.
• Encourage him to balance rest with exercise to maintain muscle
tone without developing severe fatigue.

59. SUMMARY
• LEUKEMIA is a blood cancer caused by a rise in the number of WBC’s in
your body.
• Those white blood cells crowd out the red blood cells and platelets that your
body needs to be healthy. Extra white blood cells don’t work right .
• Types : 1. acute lymphocytic leukemia(ALL) , 2. acute myelogenous
leukemia(AML), 3. chronic lymphocytic leukemia(CLL), chronic
myelogenous leukemia(CML)
• Caused by smoke, radiation, chemotherapy, family history, down syndrome

60. Cont…
• Diagnosed by: blood test , bone marrow biopsy, spinal tap, imaging test
• Treatment: radiation , biologic therapy, stem cell transplant.

61. EVALUATION
• WHAT IS LEUKEMIA?
• WHAT ARE NORMAL BLOOD CELLS, AND WHAT DO THEY DO?
• CAN LEUKEMIA BE PREVENTED?
• WHAT ARE THE ETIOLOGY OR RISK FACTORS OF LEUKEMIA?
• WHAT ARE THE SYMPTOMS OF LEUKEMIA?
• WHAT ARE THE DIFFERENT TYPES OF LEUKEMIA?
• HOW IS LEUKEMIA TREATED?
• WHAT IS THE PATHOPHYSIOLOGY OF LEUKEMIA?

62. REFERENCE
• BOOK
• INTERNET
• TEACHER

63. BIBLIOGRAPHY
• PV a text book of medical surgical nursing 11 page no. 857- 864.
• Ansari Javed , textbook of medical surgical nursing , vol - 2, PV publications,
page no. 953-967.
• Brunner and Suddarth’s textbook of medical surgical nursing, south Asia
edition , vol- 2 , Wolters Kluwer publication , page no-1142-1156
• www.wikipedia .com
• www.leukemiaslideshare.com