Leukemia refers to a group of cancers affecting the blood and other blood-forming tissues of the lymphatic system, bone marrow, and spleen. Leukemia is the most common childhood cancer but can occur in all age groups.
Like other cancers, leukemia results from a mutation in the DNA of cells. Leukemia may occur from a combination of environmental and genetic factors. Other risk factors include exposure to chemicals and pesticides, radiation, viruses, and smoking.
Leukemia can be classified depending on the type of white blood cell involved. Acute forms of leukemia occur rapidly and require aggressive treatment while chronic forms progress slowly and may go undiagnosed for years.
- Acute Lymphocytic Leukemia (ALL) is the most common type of leukemia in children and is characterized by the rapid proliferation of immature lymphocytes in the bone marrow. Clinical manifestations include fever, pallor, anorexia, bleeding, fatigue, weakness, bone, joint, and abdominal pain, generalized lymphadenopathy, and weight loss.
- Acute Myelogenous Leukemia (AML) is characterized by uncontrolled proliferation of myeloblasts and hyperplasia of the bone marrow. Clinical manifestations include fatigue, weakness, mouth sores, headache, bleeding, fever, anemia, and gingival hyperplasia.
- Chronic Lymphocytic Leukemia (CLL) is the most common type occurring in adults and is characterized by the production and accumulation of functionally inactive mature-appearing lymphocytes. Typically, there are no symptoms noted during the early onset of the disease but the patient may experience fatigue, weakness, sternal tenderness, fever, weight loss, and bone and joint pain.
- Chronic Myelogenous Leukemia (CML) occurs mainly in older adults and frequently does not show symptoms early on, but the patient may exhibit night sweats, frequent infections, weight loss, fatigue, and fever later on.
The primary methods of diagnosing and classifying leukemia are blood tests to evaluate red blood cells, white blood cells, and platelets and bone marrow examination.
The Nursing Process
Leukemia is a progressive condition and can be fatal if left untreated. While there is no cure for leukemia, attaining remission is a realistic option for some patients. Nurses support patients with leukemia by providing supportive care, especially for those who are undergoing chemotherapy, radiation, and other biologic therapies. It is essential to provide comfort measures, manage and prevent complications, provide patient and family education, and provide continuous psychological support.
Nursing Care Plans Related to Leukemia
Chronic Pain
Bone pain is common in patients diagnosed with leukemia. Pain occurs when the bone marrow expands from the accumulation of abnormal white blood cells. This is commonly felt in the arms and legs. Chemotherapy also causes neuropathic pain described as tingling, numbness, and shooting sensation in the hands and feet.
Nursing Diagnosis: Chronic Pain
Related to:
- Chemical agents (chemotherapy treatment)
- Disease process (bone marrow with excess leukemic cells, enlarged lymph nodes)
As evidenced by:
- Expressions of pain
- Diaphoresis
- Distraction behavior
- Guarding behavior
- Reports pain intensity
- Reports pain characteristics
Expected outcomes:
- The patient will report a reduced pain level following the administration of pain medication.
- The patient will verbalize two nonpharmacologic strategies to control pain
Assessment:
1. Conduct a comprehensive pain assessment.
Proper and accurate pain assessment in patients with leukemia can help determine the cause of pain which can be due to the disease process, complications, or treatments.
2. Assess and monitor vital signs and any non-verbal cues.
Pain can cause significant alterations in vital signs including increased heart rate, respiratory rate, and blood pressure. Since leukemia can affect children as well, it is important to evaluate non-verbal cues that can indicate pain or assess using the FACES scale.
Interventions:
1. Discuss marijuana compounds.
Marijuana has been shown to relieve pain and reduce inflammation. Inhaled or vaporized forms of marijuana can help treat neuropathic pain.
2. Offer complementary therapy.
Supportive treatments along with medical treatment can provide symptom relief. This may include meditation, yoga, nutritional support, acupuncture, and more.
3. Provide nonpharmacologic pain relief options.
Providing comfort is a priority for patients with oncologic pain. Nonpharmacologic methods to relieve pain include massage, psychological support, diversional activities, heating pads, or ice packs.
4. Administer pain medications as ordered.
Analgesics and antianxiety medications may be ordered to help relieve pain and support relaxation in patients with leukemia. For severe pain, opioid medications may be administered as ordered.
Fatigue
Leukemia can cause an overwhelming sense of exhaustion or fatigue which affects the patient mentally and physically. Like other blood cancers, leukemia can directly cause anemia which prevents the bone marrow from producing healthy and normal blood cells to support oxygenation.
Nursing Diagnosis: Fatigue
Related to:
- Disease process
- Pain
- Anemia
- Increased mental exertion
- Increased physical exertion
- Chemotherapy
As evidenced by:
- Apathy
- Difficulty maintaining usual physical activity
- Difficulty maintaining everyday routines
- Drowsiness
- Expresses a lack of energy
- Expresses tiredness
- Expresses weakness
- Inadequate role performance
- Exhaustion with minimal activity
- Increased need for resting or naps
Expected outcomes:
- The patient will demonstrate ways to increase energy and improve activity performance
- The patient will report a boost in energy and ability to perform physical and mental activities
Assessment:
1. Assess the severity of fatigue.
Cancer-related fatigue is a common symptom in patients diagnosed with leukemia. Proper assessment is critical as it can adversely affect health-related quality of life. This can also warrant the need for further referrals, workups, and treatment.
2. Monitor and assess laboratory values.
Fatigue can be difficult to assess. In leukemia, it is vital to identify an underlying physical issue like anemia, infection, and side effects of chemotherapy treatment, in addition to cancer.
Interventions:
1. Encourage the patient to express feelings about fatigue.
Allowing patients with leukemia to verbalize feelings about the disease process will help set realistic goals and maintain a sense of control.
2. Discuss mental health support.
Counseling may help with understanding and coping with the loss of energy. A therapist can offer strategies to manage brain fog.
3. Encourage asking for help.
Treatments for leukemia require an enormous amount of effort and time. Remind the patient that seeking the assistance of friends and loved ones is expected during this time.
4. Encourage planned exercise activities.
Continued physical activity after chemotherapy is associated with improved physical, social and mental functioning and promotes a better quality of life. Children with leukemia will often desire play but may need limits set to not overexert themselves.
Risk for Infection
Patients with leukemia are at risk for developing infections as they have a low white blood cell count and a compromised immune system. In addition, cancer treatments like chemotherapy can destroy both cancer and healthy infection-fighting white blood cells.
Nursing Diagnosis: Risk for Infection
Related to:
- Chemotherapy side effects
- Anemia
- Disease process
- Immunosuppression
- Leukopenia
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred yet and nursing interventions are directed at preventing symptoms.
Expected outcomes:
- The patient will demonstrate interventions to prevent infection and remain free from symptoms of infection
- The patient will not develop an infection
Assessment:
1. Assess factors contributing to an increased risk for infection.
Age (very young or very old) and other conditions such as viruses or chronic diseases increase the risk for infection.
2. Monitor CBC values.
It is important to acquire baseline laboratory values in patients with leukemia and to continue monitoring changes in these values. Patients with leukemia will exhibit higher than normal levels of white blood cells and lower counts of red blood cells and platelets. Alterations of these values compared to the baseline data can indicate the progression of the disease and the need for intervention.
Interventions:
1. Isolate the patient and admit them to a private room.
Patients with leukemia especially those on chemotherapy will exhibit neutropenia and bone marrow suppression, increasing the risk of infection. Placing the patient in a private room with limited visitors can protect the patient from potentially harmful pathogens.
2. Always perform handwashing before and after caring for the patient.
Hand hygiene is important to prevent the possibility of cross-contamination and the risk of infection. Educate children on handwashing practices and using alcohol-based hand sanitizers.
3. Promote infection control measures.
Infection control interventions like changing IV tubing, proper skincare, and oral hygiene can help reduce the risk of infection. Encourage the patient to wear a mask in crowded areas.
4. Administer antibiotics as ordered.
Antibiotics may be provided prophylactically to prevent infections, especially if undergoing an invasive procedure.
5. Provide a nutritious diet and refer to a dietitian as necessary.
Providing adequate nutrition can help enhance the patient’s immune system, reducing the risk of infection.
References and Sources
- ACCN Essentials of Critical Care Nursing. 3rd Edition. Suzanne M. Burns, MSN, RRT, ACNP, CCRN, FAAN, FCCM, FAANP. 2014. McGraw Hill Education.
- Acute leukemia presenting as bone pain with normal white blood cell count. Acute Med Surg. Sakata H, Nakao A, Matsuda K, Yoshie N, Yamada T, Osako T, Iwano M, Kotani J. 2014 May 19;1(4):249. DOI: 10.1002/ams2.46. PMID: 29930859; PMCID: PMC5997232.
- Leukemia. American Society of Hematology. 2022. From: https://www.hematology.org/education/patients/blood-cancers/leukemia
- Leukemia. Cleveland Clinic. Reviewed: May 18, 2022. From: https://my.clevelandclinic.org/health/diseases/4365-leukemia
- Leukemia. Leukemia & Lymphoma Society. 2022. From: https://www.lls.org/leukemia
- Leukemia. Mayo Clinic. Reviewed: Sept 21, 2022. From: https://www.mayoclinic.org/diseases-conditions/leukemia/symptoms-causes/syc-20374373
- Leukemia. National Cancer Institute. National Institutes of Health. 2022. From: https://www.cancer.gov/types/leukemia/hp
- Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. 9th Edition. Donna D. Ignatavicius, MS, RN, CNE, ANEF. 2018. Elsevier, Inc.
