Leukemia, Acute Nursing Care Plan Notes



There are two major forms of acute leukemia: lymphocytic leukemia and nonlymphocytic leukemia. Lymphocytic leukemia involves the lymphocytes (cells that are derived from the stem cells and circulate among the blood, lymph nodes, and lymphatic organs) and lymphoid organs; nonlymphocytic leukemia involves hematopoietic stem cells that differentiate into monocytes, granulocytes, red blood cells (RBCs), and platelets. Up to 90% of acute leukemias are a form of lymphocytic leukemia, acute lymphoblastic leukemia (ALL), which is characterized by the abnormal growth of lymphocyte precursors called lymphoblasts. Acute myelogenous leukemia (AML) (also known as acute nonlymphocytic leukemia, or ANLL) causes the rapid accumulation of megakaryocytes (precursors to platelets), monocytes, granulocytes, and RBCs. As the disease progresses, the patient may have central nervous system (CNS) dysfunction with seizures, decreased mental status, or coma and renal insufficiency. Death occurs when the abnormal cells encroach on vital tissues and cause complications and organ dysfunction.

  • The exact cause of acute leukemia is unknown, but there are several risk factors. Overexposure to radiation even years before the development of the disease, particularly if the exposure is prolonged, is a major risk factor. Other risk factors include exposure to certain chemicals (benzene),medications (alkylating agents used to treat other cancers in particular), and viruses. Other related factors in children include genetic abnormalities such as Down syndrome, albinism, and congenital immunodeficiency syndrome. People who have been treated with chemotherapeutic agents for other forms of cancer have an increased risk for developing AML. Such cases generally develop within 9 years of chemotherapy.
Signs and Symptoms
  • The patient appears acutely ill, short of breath, and pale.
  • Children are often febrile.
  • When you inspect the lips and mouth, you may note bleeding gums and ulcerated areas of the mouth and throat.
  • On palpation, you may feel lymph node swelling and enlargement of the liver and spleen.
  • When you auscultate the patient’s lungs, you may hear decreased breath sounds, shallow and rapid respirations, a rapid heart rate, and a systolic ejectionmurmur.


Diagnostic Evaluation
  1. CBC and blood smear – peripheral WBC count varies widely from 1,000 to 100,000/mm3 and may include significant numbers of abnormal immature (blast) cells, anemia may be profound; platelet count may be abnormal and coagulopathies may exist.
  2. Bone marrow aspiration and biopsy – cells also studied for chromosomal abnormalities (cytogenetics) and immunologic markers to classify type of leukemia further.
  3. Lymph node biopsy – to detect the spread.
  4. Lumbar puncture and examination of cerebrospinal fluid for leukemic cells (especially ALL).
  • Risk for infection related to decreased primary and secondary responses
  • OUTCOMES. Immune status; Knowledge: Infection control; Risk control; Risk detection;Nutrition status; Treatment behavior: Illness or injury; Hydration; Knowledge: Infection control
  • INTERVENTIONS. Infection control; Infection protection; Surveillance; Fluid/electrolyte management; Medication management; Temperature regulation
Pharmacologic Interventions
Different types of leukemia are best treated with different kinds of medicine.
  • Acute lymphoblastic leukemia (ALL) drugs include prednisone, vincristine, daunorubicin, L-asparaginase or pegaspargase, methotrexate, and cyclophosphamide. Imatinib (Gleevec) is sometimes used to treat ALL. Dasatinib (Sprycel) is a newer drug for treating some ALL that has not improved with other drugs.
  • Acute myelogenous leukemia (AML) drugs include daunorubicin, idarubicin, cytosine arabinoside, and mitoxantrone.10 Gemtuzumab (Mylotarg) may be given to people whose AML has relapsed. It helps your body destroy cancer cells.
  • Acute promyelocytic leukemia (APL) drugs include all-trans-retinoic acid (ATRA) and chemotherapy with arsenic trioxide, idarubicin, or daunorubicin. ATRA helps control the risk of life-threatening bleeding from disseminated intravascular coagulation (DIC). Later treatment can include ATRA with or without methotrexate and 6-mercaptopurine. Or if a first round of ATRA and chemotherapy does not work, arsenic trioxide may be used.
  • To treat leukemia in the brain or prevent it from spreading to the brain and central nervous system, methotrexate and cytarabine/cytosine arabinoside are injected into the spinal canal. This is called intrathecal chemotherapy.
Supportive treatments during cancer treatment include:
  • Antibiotics and immunoglobulins help to prevent or fight infections. This is important when you do not have enough normal white blood cells to fight infections on your own.
  • Transfusions of red blood cells and platelets.
  • Epoetin and hematopoietic stimulants help your body make new blood cells.
  • Allopurinol to prevent kidney problems and gout.
  • Saline or steroid eyedrops for relief during treatment with cytarabine/cytosine arabinoside.
Medical Management
  • The treatment for acute leukemia occurs in four phases: induction, consolidation, continuation, and treatment of (CNS) leukemia. During the induction phase, the patient receives an intense course of chemotherapy that is meant to cause a complete remission of the disease. Complete remission occurs when the patient has less than 5% of the bone marrow cells as blast cells and the peripheral blood counts are normal. Once remission has been sustained for 1 month, the patient enters the consolidation phase, during which she or he receives a modified course of chemotherapy to eradicate any remaining disease. The continuation, or maintenance, phase may continue for more than a year, during which time the patient receives small doses of chemotherapy every 3 to 4 weeks. Treatment of CNS leukemia is an essential component of therapy that has replaced irradiation, which leads to significant CNS complications, with intensive intrathecal and systemic chemotherapy for most patients.
  • Some patients also need transfusions with blood component therapy to control infection and prevent bleeding and anemia. Bone marrow transplantation (BMT) is an option for some patients. Early BMTs were allogenic transplants using stem cells that had been harvested from bone marrow from siblings or matched from unrelated relatives. In autologous BMTs in the 1980s, physicians began using frozen cells harvested from the donor’s own marrow during remission. More recently, a newer form of transplant has occurred with peripheral blood stem cell transplant (SCT) or peripheral blood progenitor cell transplant. Multiple pheresis, or removal of cells from the blood, provides the stem cells from the patient for transplantation. SCT permits the use of doses of chemotherapy and radiation therapy high enough to destroy the patient’s bone marrow; after the treatment is completed SCT restores blood-producing bone marrow stem cells. Radiation treatment is sometimes used to treat leukemic cells in the brain, spinal cord, or testicles.
Nursing Interventions
Preventing infection:
  • Frequently monitor the client for pneumonia, pharyngitis, esophagitis, perianal cellulitis, urinary tract infection, and cellulitis, which are common in leukemia and which carry significant morbidity and mortality.
  • Monitor for fever, flushed appearance, chills, tachycardia; appearance of white patches in the mouth; redness, swelling, heat or pain in the eyes, ears, throat, skin, joints, abdomen, rectal and perineal areas; cough, changes in sputum; skin rash.
  • Check results of granulocyte counts. Concentrations less than 500/mm3 put the patient at serious risk for infection.
  • Avoid invasive procedures and trauma to skin or mucous membrane to prevent entry of microorganisms.
  • Use the following rectal precautions to prevent infections: Avoid diarrhea and constipation, which can irritate the rectal mucosa, avoid the use of rectal thermometers, and keep perineal are clean.
  • Care for the patient in private room with strict handwashing practice.
  • Encourage and assist patient with personal hygiene, bathing, and oral care.
  • Obtain cultures and administer antimicrobials promptly as directed.
Preventing and Managing bleeding:
  • Watch for signs of minor bleeding, such as petechiae, ecchymosis, conjunctival hemorrhage, epistaxis, bleeding gums, bleeding at puncture sites, vaginal spotting, heavy menses.
  • Be alert for signs of serious bleeding, such as headache with change in responsiveness, blurred vision, hemoptysis, hematemesis, melena, hypotension, tachycardia, dizziness.
  • Test all urine, stool, emesis for gross and occult blood.
  • Monitor platelet counts daily.
  • Administer blood components as directed.
  • Keep patient on bed rest during bleeding episodes.
Patient Education and Health Maintenance:
  • Teach signs and symptoms of infection and advise whom to notify.
  • Encourage adequate nutrition to prevent emaciation from chemotherapy.
  • Teach avoidance of constipation with increased fluid and fiber, and good perineal care.
  • Teach bleeding precautions.
  • Encourage regular dental visits to detect and treat dental infections and disease.