Introduction
Replacement of bone marrow by abnormal cells results in unregulated proliferation
of immature white blood cells entering the circulatory system. These leukemic cells
may also enter the liver, spleen, or lymph nodes, causing these areas to enlarge.
Leukemia is classified according to the type of cell it is derived from, lymphocytic
or myelocytic, and as either acute or chronic. Lymphocytic leukemias involve imma-
ture lymphocytes originating in the bone marrow and typically infiltrate the spleen,
lymph nodes, or central nervous system. Myelogenous or myelocytic leukemia
involves the myeloid stem cells in the bone marrow and interferes with the matura-
tion of all blood cell types (granulocytes, erythrocytes, thrombocytes).
The exact cause of leukemia is unknown. There is a higher incidence in people
who have been exposed to high levels of radiation, who have had exposure to ben-
zene, or who have a history of aggressive chemotherapy for a different type of can-
cer. There may be a genetic predisposition to develop acute leukemia. Patients
with Down’s syndrome, Fanconi’s anemia, or a family history of leukemia also
have a higher-than-average incidence of this disease.
SIGNS AND SYMPTOMS
• Acute patients:
• Fatigue and weakness due to anemia
• Fever due to increased susceptibility to infection
• Bleeding, petechiae, ecchymosis (bruising), epistaxis (nosebleed), gingival
(gum) bleeding—due to decreased platelet count
• Bone pain due to bone infiltration and marrow expansion
• Lymph nodes (lymphadenopathy) enlarged as leukemic cells invade nodes
• Liver (hepatomegaly) and spleen (splenomegaly) enlarged as leukemic cells
invade
• Headache, nausea, vomiting, and weight loss
• Papilledema, cranial nerve palsies, seizure if there is central nervous sys-
tem involvement
• Chronic patients:
• Fatigue due to anemia
• Weight loss due to chronic disease process and loss of appetite
• Poor appetite
• Enlarged lymph nodes (lymphadenopathy) due to infiltration of lymph nodes
• Enlarged spleen (splenomegaly) due to involvement of the spleen
TREATMENT
• Acute myelogenous leukemia.
• Administer an anthracycline (idarubicin or daunorubicin) plus cytarabine.
• Combination: Daunorubicin, vincristine, prednisone, asparaginase.
• Administer platelet transfusions.
• Administer Filgrastim for neutropenia.
• Administer antibiotics for infections.
• Bone marrow transplant.
• Administer immunosuppressives to avoid transplant rejection.
• Chronic myelogenous leukemia.
• Administer Signal transduction inhibitor:
• Imatinib
• Interferon-α
• Busulfan
• Hydroxyurea
• Chronic lymphocytic leukemia.
• Administer alkylating agents:
• cyclophosphamide
• chlorambucil
• Administer antienoplastics:
• Vincristine
• Prednisone
• Doxorubicin
• Monoclonal antibody targeted therapy:
• alemtuzumab
• Combination of fludarabine and rituxumab.
• Transfusion if hemolytic anemia or bleeding:
• Packed RBCs.
• Whole blood.
• Platelets.
• Bone marrow transplant and immunosuppression.
• High protein diet.
NURSING DIAGNOSES
• Risk for infection
• Chronic pain
• Imbalanced nutrition, less than what body requires
NURSING INTERVENTION
• Monitor for bleeding—platelet count may be decreased.
• Monitor for infection—patients have increased susceptibility to infection.
• Monitor pain control.
• Small, frequent meals.
• Teach patients about infection control:
• Avoid others with infection.
• Report signs of infection, sore throat, fevers, etc.
• Explain to the patient:
• Use an electric razor.
• Use soft toothbrush.
• Watch for bleeding or bruising.
Introduction
The patient is missing a coagulation factor that is essential for normal blood
clotting and as a result the blood does not clot when the patient bleeds. It is an
X-linked recessive inherited disorder, passed on so that it presents symptoms in
males, and rarely in females. Hemophilia A is the result of missing clotting factor
VIII. Hemophilia B is the result of missing clotting factor IX and is also known as
Christmas disease.
SIGNS AND SYMPTOMS
• Tender joints due to bleeding
• Swelling of knees, ankles, hips, and elbows due to bleeding
• Blood in stool (tarry stool) due to GI blood loss
• Blood in the urine (hematuria)
TREATMENT
• Avoid aspirin.
• For hemophilia A administer factor VIII concentrates.
• Cryoprecipitate.
• DDAVP for patients with mild deficiency.
• For hemophilia B administer factor IX concentrates.
NURSING DIAGNOSES
• Acute pain
• Impaired gas exchange
NURSING INTERVENTION
• No IM injections.
• No aspirin.
• To stop bleeding:
• Elevate site.
• Apply direct pressure to the site.
• Explain to the patient:
• Wear a medical alert identification.
• Contact physician for any injury.
• Avoid situations where injury might occur.
