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Leukemia: Nursing Diagnoses, Care Plans, Assessment & Interventions

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. The overproduction of abnormal cells crowd out healthy blood cells, resulting in a lack of oxygenated cells, poor blood clotting, and an inability to fight infection.

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 is classified according to the rate at which the condition progresses and whether the leukemia cells come from lymphoid or myeloid cells.

By disease progression rate:

  • Acute Leukemia:
    • Cells divide fast
    • Advances rapidly
    • Needs aggressive and timely management
    • Most common in children
  • Chronic Leukemia:
    • Cells behave as mature yet dysfunctional blood cells
    • Progresses slowly
    • May have a “watch and wait” treatment approach
    • More common in adults

By type of affected cell:

  • Myelogenous or myeloid leukemia:
    • Originates from myeloid cells: red blood cells, white blood cells (other than lymphocytes), and platelets
  • Lymphocytic leukemia:
    • Originates from lymphoid cells: white blood cells (lymphocytes)

Common Types

The four most common types of leukemia are:

1. 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.

2. Acute Myelogenous Leukemia (AML) is the most common acute form in adults and 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.

3. Chronic Lymphocytic Leukemia (CLL) is the most common chronic type occurring in older adults and is characterized by the production and accumulation of functionally inactive mature-appearing lymphocytes. Typically, no symptoms are 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.

4. Chronic Myelogenous Leukemia (CML) occurs mainly in adults. It frequently does not show symptoms early on, but the patient may exhibit night sweats, frequent infections, weight loss, fatigue, and fever later on.

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 manage and prevent complications, provide comfort measures, patient and family education, and continuous emotional support.

Nursing Assessment

The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to leukemia.

Review of Health History

1. Assess the patient’s general symptoms.
Depending on the type of leukemia, symptoms would include:

  • Fever
  • Fatigue and weakness
  • Persistent infections
  • Unintended weight loss
  • Swollen lymph nodes
  • Easy bruising or bleeding
  • Night sweats
  • Shortness of breath
  • Bone or joint pain

2. Determine the patient’s nonmodifiable risk factors.
The following factors that could raise the incidence of certain types of leukemia include:

  • Age: children under 15 or adults over age 50.
  • Gender: males are slightly more likely than females to develop leukemia.
  • Race: Caucasian/white ethnicity carries a higher risk of leukemia.
  • Family history: Most cases of leukemia don’t have a familial link, but those with a close relative (parent, sibling) who have AML or CLL may be at higher risk.
  • Congenital diseases: Conditions like Down syndrome or bone marrow disorders increase the risk of acute leukemias.

3. Assess for smoking.
Smoking is the only proven modifiable risk factor for AML. Ask the client if they have a history of smoking.

4. Review the patient’s medical history.
The risk of leukemia may increase if there is a previous history of radiation exposure or chemotherapy treatment.

5. Identify a possible exposure to chemicals.
Chemicals known to cause cancer, like benzene and formaldehyde, are present in the following household products and manufacturing materials:

  • Benzene-containing products:
    • Plastics
    • Rubber
    • Dyes
    • Insecticides
    • Medications
    • Detergents 
    • Cigarette smoke
    • Motor vehicle exhaust
  • Formaldehyde-containing products:
    • Building materials
    • Glues, paints, lacquers
    • Cleaning supplies

Physical Assessment

1. Monitor for flu-like symptoms.
Patients with leukemia may become sick frequently due to a lack of healthy white blood cells. They may experience persistent fever, lymphadenopathy, and fatigue.

2. Assess the abdomen.
Hepatosplenomegaly (enlarged liver and spleen) occurs from the accumulation of abnormal cells. To check for liver enlargement, palpate for the liver size using one or two hands, palms down, and working upward 2-3 cm at a time. Note if the liver is soft, firm, rigid, or nodular.

3. Assess for a change in weight.
Unexplained weight loss may be observed.

4. Check for pain in the joints or bones.
Note for any bone or joint pain. Bone pain is commonly reported in the following locations:

  • Ribs
  • Breastbone
  • Hips
  • Shoulders
  • Long bones of the arms and legs 

Joint pain and swelling may develop later.

5. Assess for symptoms of anemia.
A dysfunction in red blood cells may result in anemia, causing symptoms like:

  • Shortness of breath 
  • Easy fatigability
  • Pallor

6. Monitor for bleeding.
A dysfunction in platelets causing thrombocytopenia results in symptoms like:

  • Easy bruising 
  • Pinpoint rashes (petechiae)
  • Frequent nosebleeds
  • Gum bleeding
  • Blood in the urine or stool

Diagnostic Procedures

1. Obtain blood for testing.
Numerous tests are necessary to diagnose leukemia. Initially, the following blood tests will be completed:

  • Complete blood count (CBC)
  • Comprehensive metabolic panel
  • Liver and kidney function tests 
  • Coagulation panel (prothrombin time [PT], activated partial thromboplastin time [aPTT], fibrinogen)

2. Conduct further blood tests.
The healthcare provider may request additional blood tests to assess for the presence of leukemia cells through the following:

  • Peripheral blood smear
  • Flow cytometry

3. Prepare the patient for bone marrow aspiration/biopsy.
The diagnosis of leukemia is confirmed by bone marrow aspiration and/or biopsy. During bone marrow aspiration/biopsy, sample fluid is drawn out of the bone marrow, usually via the back of the hip bone. 

4. Perform imaging tests or procedures to assess the effects on other organs.
Imaging does not reveal leukemia cells, though it may show the effects of leukemia on the bones, organs, or tissues. These tests include:

  • Chest X-ray
  • CT scan
  • Magnetic resonance imaging (MRI) scan
  • Lumbar puncture: A sample of spinal fluid is obtained through a lumbar puncture to determine if leukemia has advanced to include the central nervous system.

Nursing Interventions

Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for a patient with leukemia.

1. Collaborate with the oncologist/hematologist regarding the treatment plan.
The healthcare team will decide on the best treatment options depending on the following:

  • The patient’s current health status
  • The type of leukemia 
  • The presence of metastasis to other parts of the body

2. Educate on treatment phases.
Chemotherapy is necessary to eradicate cancer cells. Chemotherapy for ALL specifically follows these three phases:

  • Induction therapy:
    • Goal: eradicate all leukemia cells from the blood and bone marrow to establish remission. 
    • Blood cell counts return to normal, and no leukemia cells are found in the bone marrow.
    • 95% of children reach remission in one month.
  • Consolidation (also called intensification):
    • Goal: eradicate any remaining leukemia cells to prevent cancer resistance.
    • Administered in cycles over a four- to six-month period.
  • Maintenance therapy:
    • Goal: Maintain remission using a combination of oral chemotherapy, immunosuppressives, and steroids.
    • Lasts two years.

3. Implement the treatment care plan.
The following treatments may be combined for effective results:

  • Chemotherapy
  • Targeted therapy
  • Radiation therapy
  • Immunotherapy
  • Hematopoietic cell transplant (stem cell or bone marrow transplant)

4. Manage the side effects of cancer treatment modalities.
Treatments not only affect cancer cells, but also healthy cells. The following side effects may be observed:

  • Infection
  • Bleeding and bruising
  • Anemia
  • Fatigue
  • Lymphedema
  • Hair loss 
  • Loss of appetite 
  • Nausea and vomiting
  • Poor concentration and memory
  • Constipation/diarrhea
  • Mouth sores or thrush
  • Skin and nail changes

5. Provide skin care after radiation.
Intense energy beams or X-rays destroy leukemia cells or limit their growth. Redness and irritation are normal after radiation therapy. Moisturizers can be applied after treatment (not before). Protect the skin from hot or cold temperatures, wear loose cotton clothing, do not shave the area (may use an electric razor), and cleanse using warm water and soaps without fragrances. 

6. Boost the immune system to fight cancer cells.
Immunotherapy (biologic therapy) strengthens the body’s immune system to fight leukemia. 

7. Consider CAR T-cell therapy.
Chimeric antigen receptor (CAR) T-cell treatment is a type of immunotherapy that modifies the immune system’s T cells (T lymphocytes) to recognize and destroy cancerous cells. This treatment is often reserved for cases when chemotherapy has been unsuccessful.

8. Attack the cancer cell.
Targeted therapy involves drugs created to target particular components of a leukemia cell (such as a protein or gene) causing the abnormality. Targeted therapy may stop leukemia cells from proliferating, cut off their blood supply, or directly destroy the cells. Targeted therapy has a lower risk of damaging healthy cells. Drugs used in targeted therapy include:

  • Tyrosine kinase inhibitors 
  • Monoclonal antibodies

9. Prepare the patient for a possible hematopoietic cell transplant.
Damaged or cancerous cells are replaced with healthy cells during a hematopoietic cell transplant (also known as stem cell or bone marrow transplant). The goal is for healthy cells to generate functional blood cells. Bone marrow/stem cell transplants may cure some types of leukemia.

10. Educate the patient on available clinical trials.
Clinical trials are experiments to see how well new and existing cancer therapies work. Clinical trials allow the patient to try new advancements in cancer treatment, though there may be unknown risks involved, or the treatment may be ineffective. Patients can discuss participating in clinical trials with their healthcare provider.

11. Implement neutropenic precautions.
Neutropenic precautions are applied when a patient is immunocompromised and has a low neutrophil count. Precautions include:

  • Meticulous hand hygiene
  • Assigning the patient to an isolated room
  • Limiting visitation
  • Avoiding unnecessary invasive procedures such as rectal temperatures or the insertion of suppositories
  • Avoiding large crowds and sick people
  • No flowers or live plants in the the room

12. Educate on a neutropenic diet.
New research indicates that neutropenic diets may be unnecessary. If advised by the healthcare provider, the patient should follow these guidelines:

  • Refrain from eating raw and fresh food (such as fruits and vegetables)
  • Avoid raw or undercooked meats and eggs
  • Do not share food or drinks
  • Do not consume unpasteurized milks or cheeses

13. Transfuse blood as ordered.
The leukemia treatment regimen may occasionally include blood transfusions that aid in alleviating some cancer symptoms like anemia or bleeding but do not treat the cancer specifically.

14. Administer growth factors as prescribed.
Administer growth factors as ordered before harvesting stem cells for a stem cell transplant. Growth factors stimulate the development of new blood cells in the bone marrow. Granulocyte colony-stimulating factor stimulates the production of WBCs, erythropoietin stimulates new RBCs, and thrombopoietin stimulates platelet growth.

15. Provide immunosuppressants as ordered.
Immunosuppressive therapy reduces the body’s immunological response so the body won’t reject new stem cells. Immunosuppressants such as corticosteroids may also be given to reduce the side effects of cancer treatments. 

16. Emphasize when to seek immediate medical attention.
Seek emergency medical attention if there is a suspected infection. Neutropenia-related infections are potentially fatal and necessitate immediate medical attention. Advise the patient to go immediately to an emergency room if they have any signs of infection, such as a temperature of 100.4°F (38°C) or higher, chills, a new cough, sore throat, or cuts or scrapes that are red, swollen, or draining.

17. Support the patient’s mental and emotional well-being.
Leukemia can be heartbreaking, especially for the family of a young patient. Support the patient and their families and offer plenty of resources to reduce financial, emotional, and caregiving burdens.

Nursing Care Plans

Once the nurse identifies nursing diagnoses for leukemia, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for 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

  • 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:

  • Patient will report a reduced pain level following the administration of pain medication.
  • Patient will verbalize two nonpharmacologic strategies to control pain.


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.


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.


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

  • 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:

  • Patient will demonstrate ways to increase energy and improve activity performance.
  • Patient will report a boost in energy and ability to perform physical and mental activities.


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.


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 Decreased Cardiac Output

Physiological changes from leukemia, as well as cancer treatments, increase the risk of developing cardiac infections, heart failure, and ischemia.

Nursing Diagnosis: Decreased Cardiac Output

  • Cancer cells infiltrating cardiac cells
  • Inadequate oxygenated blood to the heart
  • Inflammation
  • Immunosuppression
  • Cancer treatments (anthracyclines)

As evidenced by:

A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are aimed at prevention.

Expected outcomes:

  • Patient will not develop heart failure, endocarditis, or pericarditis.
  • Patient will display normal sinus rhythm on ECG.
  • Patient will verbalize two strategies to prevent developing heart disease.


1. Monitor if taking anthracyclines.
Anthracyclines (such as idarubicin or doxorubicin) are a class of drugs used in chemotherapy that have been shown to damage cardiac cells and the pumping ability of the heart. The nurse should monitor for signs of cardiac toxicity, such as a change in blood pressure, activity intolerance, dyspnea, chest pain, palpitations, and edema.

2. Review echocardiogram.
An echocardiogram can assess the left ventricular ejection fraction and the patient’s risk of developing heart failure.

3. Obtain ECG.
If the client has a history of heart disease or presents with cardiac symptoms, obtain an ECG to monitor for dysrhythmias.


1. Discuss lower doses of anthracyclines.
If the patient begins experiencing heart-related side effects from these medications, the nurse can collaborate with the healthcare team on lowering doses or switching to a different medication.

2. Refer to a cardiologist.
Patients receiving treatment for leukemia are treated by a team of oncologists and hematologists. It may be prudent to involve a cardiologist if cardiac issues arise.

3. Administer prescribed medications.
Educate on the addition of medications like ACE inhibitors, beta-blockers, or diuretics to treat manifestations of heart failure such as hypertension and edema.

4. Educate on lifestyle modifications to prevent heart disease.
The patient is still in control of keeping their heart as healthy as possible while undergoing treatment for leukemia. Instruct on the following healthy habits:

  • Exercising as recommended
  • Quitting smoking
  • Maintaining a healthy weight
  • Limiting alcohol
  • Reducing the intake of saturated fats, salt, and cholesterol

Risk for Imbalanced Fluid Volume

Patients with leukemia are at risk for imbalanced fluid volume caused by symptoms of the disease and/or treatments.

Nursing Diagnosis: Risk for Imbalanced Fluid Volume

  • Cancer treatment (such as chemotherapy)
  • Presence of infection or sepsis
  • Blood transfusions
  • Adverse effects of treatment/disease
  • Kidney injury
  • Presence of cardiovascular/renal conditions

As evidenced by:

A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are aimed at prevention.

Expected outcomes:

  • Patient will maintain balanced fluid intake and output.
  • Patient will not display signs of imbalanced fluid volume, such as edema, changes in mental status, hypotension, shortness of breath, and dry mucous membranes.
  • Patient’s hemoglobin, hematocrit, and electrolytes will remain within normal limits.


1. Strictly monitor the fluid intake and output.
Ensure that the fluid intake and output are accurately documented each shift. For strict monitoring, ask the patient to note or record their intake and output (if they are ambulating). Fluid balance is calculated by taking the fluid intake and comparing it to the output. The formula used is: Fluid balance (mL) = Fluid intake (mL) – Total urine output (mL)

2. Consider symptoms causing a fluid deficit.
Nausea, vomiting, diarrhea, night sweats, and bleeding are commonly associated with symptoms of leukemia and/or chemotherapy treatment and can lead to a deficit in fluid volume.

3. Determine the patient’s comorbidities.
Note the presence of comorbidities that may influence fluid balance, such as kidney injury and cardiovascular conditions.

4. Review medications.
Certain medications may affect fluid balance or even cause acute kidney injury. These medications include:

  • Diuretics
  • Laxatives
  • Antacids
  • Anti-histamines
  • NSAIDs
  • Blood pressure medications


1. Control symptoms.
Administer medications to control symptoms of vomiting, fever, and diarrhea that result in fluid loss.

2. Closely monitor lab results.
The nurse should monitor the hemoglobin, hematocrit, coagulation profile, BUN, creatinine, and electrolyte levels for signs of bleeding, reduced kidney function, and electrolyte alterations that indicate fluid imbalances.

3. Teach the patient about the signs and symptoms of imbalanced fluid volume.
Instruct the patient on signs of dehydration and fluid overload and then have them teach back symptoms. Emphasize the need to immediately seek medical attention when symptoms are observed.

4. Administer blood products cautiously.
Patients with leukemia may require the replacement of red blood cells and platelets related to the disease process. Deliver blood products cautiously to prevent fluid overload.

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

  • 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


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.


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.


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Maegan Wagner is a registered nurse with over 10 years of healthcare experience. She earned her BSN at Western Governors University. Her nursing career has led her through many different specialties including inpatient acute care, hospice, home health, case management, travel nursing, and telehealth, but her passion lies in educating through writing for other healthcare professionals and the general public.