Saturday, February 23, 2013

DESCRIPTION

WHAT IS LEUKEMIA?
   Leukemia is a neoplasm of acute or chronic blood-forming cells in bone marrow and spleen (Reeves, 2001). The other characteristic of leukemia is the proliferation of irregular or accumulation of white blood cells in bone marrow, replace normal bone marrow elements. Proliferation also occurs in the liver, spleen, and lymph nodes. The invasion of non-haematological organs such as the meninges, gastrointestinal tract, kidney, and skin.
Acute lymphocytic leukemia (ALL) often occurs in children. Leukemia classified as acute if there is proliferation of the blastocyst (young blood cells) from bone marrow. Acute leukemia is a malignant primary bone marrow resulting in normal blood components late decision by abnormal blood components (blastocyst), accompanied by the spread of other organs. Leukemia is classified as chronic if found cell expansion and       accumulation of old and young cells (Tejawinata, 1996).

In addition to acute and chronic, there is also a congenital leukemia is leukemia were found in infants aged 4 weeks or younger infants.

SYMPTOMS, ETIOLOGY, & OCCURENCE

Symptoms
1. Anemia
Caused by red blood cell production is less a result of the failure of the bone marrow to produce red blood cells. Characterized by reduced hemoglobin concentration, a decrease in hematocrit, red blood cell count less. Children with leukemia have pale, tiredness, shortness of breath sometimes.

2. High body temperature and easy to infections
Due to a decrease in leukocytes, it will automatically lower the body resistance due to leukocytes serves to maintain the immune system can not work optimally.

3. Bleeding
Signs of bleeding can be viewed and analyzed from the presence of mucosal bleeding such as gums, nose (epistaxis) or bleeding under the skin which is often called petechiae. Bleeding may occur spontaneously or due to trauma. If very low levels of platelets, bleeding can occur spontaneously.

4. Decreased consciousness

Due to infiltration of abnormal cells to the brain can cause a variety of disorders such as seizures to coma.

5. Decrease in appetite

6. Weakness and physical exhaustion.


Etiology 

The cause of ALL until now not clear, but most likely due to a virus (oncogenic viruses).
Other factors that play a role include:


  1. Exogenous factors such as X rays, radioactive rays, and chemicals (benzol, arsenic, sulfate preparations), infections (viruses and bacteria).
  2. Endogenous factors such as race
  3. Constitutional factors such as chromosomal abnormalities, hereditary (sometimes encountered cases of leukemia in siblings or twins one egg).

Predisposing factors:

  1. Genetic factors: a certain virus causes changes in gene structure (T cell leukemia-lymphoma virus / HTLV)
  2. Ionizing radiation: the work environment, prenatal care, previous cancer treatment
  3. Exposure to chemicals such as benzene, arsenic, chloramphenicol, phenylbutazone, and anti-neoplastic agents.
  4. Immunosuppressive medications, drugs carcinogens such as diethylstilbestrol
  5. Hereditary factors such as the twins one egg
  6. Chromosomal abnormalities

If the cause of leukemia is caused by a virus, the virus will easily fit into the human body if the structure of the viral antigen is consistent with the structure of the human antigen. The structure of the human antigen is formed by the antigen structure of various organs, especially the skin and mucous membranes located on the surface of the body (tissue antigen). By WHO, tissue antigens defined by the term HL-A (human leucocyte locus A). 


Occurence

Since leukemia is always fatal, the mortality rates are a reasonably accurate reflection of the occurrence of the disease at various ages. Certain features about the occurrence of leukemia were analyzed from the Vital Statistics of the United States over a twenty year period with special reference to age. A comparison of the occurrence (mortality) during this time has shown a considerable and progressive increase in incidence in persons over 50 years of age from 1930 to 1949. In ages under 50 years the increase was apparently slight but not remarkable.
In addition a comparison of the clinical occurrence of patients with the chronic forms of leukemia has shown that, in recent years, the proportion of patients over 50 years of age is twice as great as in similar groups of patients observed some twenty years previously.
The evidence strongly suggests that the occurrence of leukemia in persons over 50 years of age is actually increasing.

MODE OF TRANSMISSION & PATHOPHYSIOLOGY

Transmission

             HTLV-I propagated in IMR90 human diploid fibroblasts was transmitted to human myeloid leukemia HL60 cells at a low efficiency. After co-cultivation for 3 months, the viral genome was detected in 14/48 HL60 cell clones. Among the 14 HTLV-I-infected clones, 8 contained subgenomic fragments alone or in addition to the complete HTLV-I genome. The frequency of deleted proviruses (9/24 total proviruses) was unexpectedly high. Hirt's supernatant of some of the clones harboring complete HTLV-I genome(s) in the chromosome contained both linear and circular HTLV-I proviral DNAs. The circular DNAs were composed of one LTR and 2 LTR closed circular proviruses. These clones produced infectious HTLV-I constitutively, which was proved by transmission of the viral genome into fresh IMR90 cells by co-cultivation. However, in these clones, re-integration of extrachromosomal provirus into their own chromosomes was not observed.

Pathophysiology
       Leukemia is malignant neoplasms of the cells derived from either the myeloid or lymphoid line of the hematopoietic stem cells in the bone marrow. Proliferating abnormal and immature cells (blast) spill out into the blood and infiltrate the spleen, lymph nodes, and other tissue. Acute leukemias are characterized by rapid progression of symptoms. High numbers (greater than 50,000/mm3) of circulating blast weaken blood vessel walls, with high risk for rupture and bleeding, including intracranial hemorrhage.Lymphocytic leukemias involve immature lymphocytes and their progenitors. They arise in the bone marrows but infiltrate the spleen, lymph nodes, central nervous system (CNS), and other tissues. Myelogenous leukemias involve the pluripotent myeloid stem cells and, thus, interfere with the maturation of granulocytes, erythrocytes, and thrombocytes. Acute myelogenous leukemias (AML) and acute lymphatic leukemia (ALL) have similar presentations and courses. Approximately half of new leukemias are acute. Approximately 85 % of acute leukemias in adults are AML, and incidence of AML increases with age. ALL is the most common cancer in children, with peak incidence between ages 2 and 9.
Although the cause of leukemias is unknown, predisposing factors include genetic susceptibility, exposure to ionizing radiation or certain chemicals and toxins, some genetic disorder (Down syndromes, Fanconi’s anemia), and human T-cell leukemia-lymphoma virus. Complications include infection, leukostasis leading to hemorrhage, renal failure, tumor lysis syndrome, and disseminating intravascular coagulation.

NURSING DIAGNOSIS


Risk for Fluid Volume Deficit

related to

  • fluid intake and output,
  • excessive loss: vomiting, bleeding, diarrhea
  • decrease in fluid intake: nausea, anorexia
  • increased need for fluids: fever, hypermetabolic.

Purpose : the volume of fluid being met

Expected outcomes:
  • Adequate fluid volume
  • The mucosa moist
  • Vital signs are stable: BP 90/60 mm Hg, pulse 100x/menit, RR 20x/menit
  • Pulse palpated
  • Urine output 30 ml / hour
  • Capillaries and refill less than 2 seconds
Acute pain 

related to an agent of physical injury

Purpose: pain is resolved

Expected outcomes:
  • The patient stated the pain disappeared or controlled
  • Shows the behavior of pain management
  • Looks relaxed and able to rest, sleep
 

TREATMENT & MANAGEMENT

Chemotherapy

Chemotherapy may be given as pills or by injection. Chemotherapy drugs interfere with the ability of cancer cells to grow and spread, but they also damage healthy cells. Although healthy cells can recover over time, you may experience side effects from your treatment like nausea, vomiting, loss of appetite, fatigue, hair loss and an increased risk of infection. 

Stem cell transplant

Sometimes high doses of chemotherapy are used to treat leukemia that has come back or if there is a high risk that it may come back. High-dose chemotherapy destroys the bone marrow cells as well as the leukemia cells, so the bone marrow will need to be replaced with a transplant of stem cells. All blood cells develop from stem cells found in the bone marrow and in the bloodstream. 

Before high-dose chemotherapy is given, stem cells will be taken from you or from a donor whose bone marrow is a close match to your own. Soon after the chemotherapy treatment, the stem cells are put back into your blood. Within a few weeks, the new stem cells will start to make blood cells.
A stem cell transplant is a very and complex procedure. For this reason, stem cell transplants are done in specialized transplant centres or hospitals by a team of highly trained healthcare professionals. Side effects can be very serious and may even be life-threatening. You will be watched very closely after a stem cell transplant and carefully followed up for a period of time after leaving the hospital. It may take several months to fully recover after a stem cell transplant.

Radiation therapy

In external beam radiation therapy, a large machine is used to carefully aim a beam of radiation. The radiation damages the cells in the path of the beam – normal cells as well as cancer cells. Radiation side effects will be different depending on what part of the body receives the radiation. You may feel more tired than usual, have some diarrhea, or notice changes to the skin (it may be red or tender) where the treatment was given.
Radiation may be used for some types of leukemia to treat the disease or prevent it from spreading. If you need a stem cell transplant, you may also be given radiation to the whole body to destroy the bone marrow cells. This is called total body irradiation.

Biological therapy

Biological therapy uses your immune system to fight cancer or to help control side effects of other cancer treatments. Natural body substances or drugs made from natural body substances are used to boost the body’s own defences against illness.

There are two forms of biological therapy used to treat leukemia: monoclonal antibodies and interferon alfa. Both are given by injection. Monoclonal antibodies are sometimes used to treat people with CLL, ALL and AML. Interferon alfa may also be used for CML (although people with CML are more likely to be treated with cancer growth inhibitors). Side effects of these drugs often cause flu-like symptoms, such as chills, fever, muscle aches, weakness and nausea. More serious side effects are rare. Some people may have a severe skin rash, breathing problems or low blood pressure. The side effects usually disappear once treatment is finished. Be sure to discuss the risks and benefits of this treatment with your healthcare team.

Targeted therapy

Targeted therapies use drugs that attack specific types of cancer cells without damaging healthy cells. Cancer growth inhibitors are a type of targeted therapy. They interfere with a cancer cell’s ability to grow and divide. Some cancer growth inhibitors can be used to treat people with CML, ALL and AML. These drugs are taken by pill or capsule. Side effects are most likely to occur during the first few months of treatment. Side effects may get better as treatment continues.

Watchful waiting

Watchful waiting is a treatment option that may be offered to people with CLL who have no symptoms. Watchful waiting means your healthcare team will watch the leukemia closely. You will visit your doctor regularly for a physical examination. Other tests may be done from time to time. Active treatment, such as chemotherapy or radiation, may be considered if signs of leukemia appear or change. Once the symptoms are controlled, you and your doctor may decide to return to a watchful waiting program.

Surgery

Surgery is rarely used to treat chronic leukemia, but some people with chronic leukemia will need to have their spleen removed. The spleen is located in the abdomen and is attached to the stomach, left kidney and colon. In chronic leukemia, the spleen may become enlarged. An enlarged spleen can cause discomfort and pain. It also destroys red blood cells and platelets, causing anemia and bleeding. If chemotherapy or radiation doesn't shrink the spleen, then it may be removed by surgery. Surgery to remove the spleen is called splenectomy. It is done under general anesthetic (you will be unconscious).
After surgery you may have some pain or bleeding. These side effects are temporary, and can usually be controlled. Without a spleen, you may be more at risk of infections.

Side Effects of treatment


Relieving Pain

Learn more about ways to manage and control your pain and discomfort, side effects and stress when you are having cancer treatments.

Coping with Cancer

Everyone’s cancer experience is different. Whether you are newly diagnosed, in active treatment, or are caring for someone with cancer, you will probably need to deal with many day-to-day issues, make tough decisions, and cope with a range of emotions.

Long-term monitoring

Growth factors may be used in order to decrease the length of neutropenia following chemotherapy in patients with (chronic lymphoid leukemia, CLL).

PREVENTION



Unfortunately, there are no proven leukemia prevention methods. Even more sadly, most of the risk factors cannot be avoided like in other types of cancer. We simply cannot avoid aging or having conditions like Down's Syndrome. There are some risk factors we can avoid that may aid in leukemia risk reduction, like not smoking. If you smoke cigarettes, now is the time to quit. Smoking puts you at risk for many types of cancer, including acute myelogenous leukemia. 1 in every 4 cases of AML is linked to smoking.

Reducing your exposure to benzene may reduce your risk of developing leukemia. Benzene is a chemical by product of coal and petroleum, used mainly is gasoline. It is also contained in other things such as paints, solvents, plastics, pesticides and detergents. People who work in the manufacturing of these products may be putting themselves at risk for leukemia.

Thursday, February 21, 2013

NURSING INTERVENTION

Risk for Fluid Volume Deficit   
  • Monitor body weight
  • Monitor fluid intake and output
  • Monitor BP and heart frequency
  • Evaluation of skin turgor, capillary refill and mucous membrane conditions
  • Give fluid intake 3-4 L / day
  • Inspection of skin / mucous membranes for petechiae, ecchymoses area; noticed bleeding gums, blood color of rust or vague in feces and urine, bleeding from the puncture further invasive.
  • Implement measures to prevent tissue injury / bleeding
  • Limit oral care to wash mouth when indicated
  • Give diet a smooth
  • Collaboration:
    • Give IV fluids as indicated
    • Supervise laboratory tests: platelet count, Hb / Ht, freezing
    • Provide HR, platelets, clotting factors
    • Maintain a central vascular access device external (sub-clavicle artery catheter, tunneld, implantable ports)
     
 Acute Pain
  • Assess complaints of pain, notice changes in the degree of pain (using a scale of 0-10)
  • Monitor vital signs, note the non-verbal clues such as muscle tension, anxiety
  • Provide quiet environment and reduce stressful stimuli.
  • Place the client in a comfortable position and prop joints, extremities with pillows.
  • Change the position of periodic and soft assistive range of motion exercises.
  • Provide comfort measures (massage, cold compresses and psychological support)
  • The review / enhance client comfort interventions
  • Evaluate and support the client's coping mechanisms
  • Encourage the use of pain management techniques. Example: relaxation exercises / breathing in, touch.
  • Auxiliary therapeutic activity, relaxation techniques.
  • Collaboration: Monitor levels of uric acid, give the medication as indicated.