Acute Lymphocytic Leukemia

Acute lymphocytic leukemia (ALL), also known as acute lymphoblastic leukemia, refers to an abnormal growth of lymphocyte precursors or lymphoblasts.

Table of Contents

• What is Acute Lymphocytic Leukemia? 
• Pathophysiology
• Statistics and Incidences
• Causes
• Clinical Manifestations
• Complications
• Assessment and Diagnostic Findings
• Medical Management
• Pharmacologic Therapy
• Surgical Management
• Nursing Management
  • Nursing Assessment
  • Nursing Diagnosis
  • Nursing Care Planning & Goals
  • Nursing Interventions
  • Evaluation
  • Discharge and Home Care Guidelines
  • Documentation Guidelines
• Practice Test: Acute Lymphocytic Leukemia

What is Acute Lymphocytic Leukemia?

Acute leukemias have large numbers of immature leukocytes and overproduction of cells in the blast stage of maturation.

• Acute lymphocytic leukemia (ALL), also known as acute lymphoblastic leukemia, refers to an abnormal growth of lymphocyte precursors or lymphoblasts.
• Acute leukemia is a malignant proliferation of white blood cell precursors in bone marrow or lymph tissue, and their accumulation in peripheral blood, bone marrow, and body tissues.
• About 20% of leukemias are acute.

Pathophysiology

Pathogenesis isn’t clearly understood, but the pathophysiology may be explained by the following:

• Accumulation. Due to the precipitating factors, immature, non-functioning WBCs appear to accumulate first in the tissue where they originate (lymphocytes in lymph tissue, granulocytes in bone marrow).
• Infiltration. These immature WBCs then spill into the bloodstream and from there infiltrate other tissues.
• Malfunction. Eventually, this infiltration results in organ malfunction because of encroachment and hemorrhage.
• Schematic diagram and pathophysiology

Statistics and Incidences

One of the most common forms of acute leukemia is acute lymphocytic leukemia.

• Acute lymphocytic leukemia is more common in males than in females, in whites (especially in people of Jewish descent), in children (between ages 2 and 5), and in people who live in urban and industrialized areas.
• 80% of all leukemias between 2 and 5 years old are ALL.
• Acute leukemias account for 20% of adult leukemias.
• Among children, however, it is the most common form of cancer.
• Incidence is 6 out of every 100, 000 people.

Causes

Research on predisposing factors isn’t conclusive but points to some combination of viruses, immunologic factors, genetic factors, and exposure to radiation and certain chemicals.

• Congenital disorders. Down syndrome, Bloom syndrome, Fanconi anemia, congenital agammaglobulinemia, and ataxia-telangiectasia usually predisposes to ALL.
• Familial tendency. Genetics also play a part in the development of ALL.
• Viruses. Viral remnants have been found in leukemic cells, so they are likely one of the causes of ALL.

Clinical Manifestations

Signs of acute lymphocytic leukemia may be gradual or abrupt.

• High fever. High fever accompanied by thrombocytopenia and abnormal bleeding (such as nosebleeds and gingival bleeding) manifests in the patient.
• Bruising. Easy bruising after minor trauma is a sign of leukemia.
• Dyspnea. A decrease in the mature blood components leads to dyspnea.
• Anemia. Anemia is present in ALL because of a decrease in mature RBCs.
• Fatigue. The patient experiences fatigue more frequently than normal.
• Tachycardia. As the oxygen-carrying component of the blood decreases, the body compensates by pumping out blood faster than normal.

Complications

Untreated, acute leukemia is invariably fatal, usually because of complications that result from leukemic cell infiltration of the bone marrow and vital organs.

• Infection. Immature WBCs are not fit to defend the body against pathogens, so infection is always a possible complication to watch out for.
• Organ malfunction. Encroachment or hemorrhage occurs when immature WBCs spill into the bloodstream and other tissues and eventually lead to organ or tissue malfunction.

Assessment and Diagnostic Findings

The diagnosis of ALL can be confirmed with a combination of the following:

• Bone marrow aspiration. Typical clinical findings and bone marrow aspirate showing a proliferation of immature WBCs confirm ALL.
• Bone marrow biopsy. A bone marrow biopsy, usually of the posterior superior iliac spine, is part of the diagnostic workup.
• Blood counts. Blood counts show severe anemia, thrombocytopenia, and neutropenia.
• Differential leukocyte count. Differential leukocyte count determines cell type.
• Lumbar puncture. Lumbar puncture detects meningeal involvement.
• Uric acid levels. Elevated uric acid levels and lactic dehydrogenase levels are commonly found.

Medical Management

With treatment, the prognosis varies.

• Systemic chemotherapy. Systemic chemotherapy aims to eradicate leukemic cells and induce remission (less than 5% of blast cells in the marrow and peripheral blood are normal).
• Radiation therapy. Radiation therapy is given for testicular infiltrations.
• Platelet transfusion is performed to prevent bleeding and RBC transfusion to prevent anemia.

Pharmacologic Therapy

ALL chemotherapy includes the following drugs and also other drugs included in the treatment:

• Vincristine. Vincristine is an anti-cancer (antineoplastic or cytotoxic) chemotherapy drug and is classified as a plant alkaloid.
• Prednisone. This drug works is by altering the body’s normal immune system responses.
• Cytarabine. Cytarabine belongs to the category of chemotherapy called antimetabolites, wherein When the cells incorporate these substances into the cellular metabolism, they are unable to divide and they attack cells at very specific phases in the cycle.
• L-asparaginase. Asparaginase breaks down asparagine in the body, so since the cancer cells cannot make more asparagine, they die.
• Daunorubicin. Daunorubicin is classified as an antitumor antibiotic which is made from natural products produced by species of the soil fungus Streptomyces, and these drugs act during multiple phases of the cell cycle and are considered cell-cycle specific.
• Antibiotic, antifungal, and antivirals. These control infection, a common complication of acute leukemias.

Surgical Management

Aggressive treatment may include surgical management through:

• Bone marrow transplant. Bone marrow transplant is a choice that can be considered for a patient with ALL.
• Stem cell transplant. Stem cell transplant in ALL is one of the latest development in the treatment of acute leukemias

Nursing Management

The care plan for the leukemic patient should emphasize comfort, minimize the adverse effects of chemotherapy, promote preservation of veins, manage complications, and provide teaching and psychological support.

Nursing Assessment

The clinical picture varies with the type pf leukemia as well as the treatment implemented, so the following must be assessed:

• Health history. The health history may reveal a range of subtle symptoms reported by the patient before the problem is detectable on physical examination.
• Physical examination. A thorough, systematic assessment incorporating all body systems is essential.
• Laboratory results. The nurse also must closely monitor the results of laboratory studies and culture results need to be reported immediately.

Nursing Diagnosis

Based on the assessment data, major nursing diagnoses for the patient with ALL may include:

• Risk for infection related to overproduction of immature WBCs.
• Risk for impaired skin integrity related to toxic effects of chemotherapy, alteration in nutrition, and impaired immobility.
• Imbalanced nutrition, less than body requirements, related to hypermetabolic state, anorexia, mucositis, pain, and nausea.
• Acute pain and discomfort related to mucositis, leukocyte infiltration of systemic tissues, fever, and infection.
• Hyperthermia related to tumor lysis or infection.
• Fatigue and activity intolerance related to anemia, infection, and deconditioning.

Nursing Care Planning & Goals

Main Article: 5 Leukemia Nursing Care Plans

The major goals for the patient may include:

• Absence of pain.
• Attainment and maintenance of adequate nutrition.
• Activity tolerance.
• Ability to provide self-care and to cope with the diagnosis and prognosis.
• Positive body image.

Nursing Interventions

The interventions included in the care plan of the patient follows.

Before treatment:

• Education. The nurse should explain the disease course, treatment, and adverse effects.
• Infection. The nurse should teach the patient and his family how to recognize symptoms of infection such as fever, chills, cough, and sore throat.
• Bleeding. The nurse should educate the patient and the family how to recognize abnormal bleeding through bruising and petechiae and how to stop it with direct pressure and ice application.
• Promote good nutrition. The nurse should explain that chemotherapy causes weight loss and anorexia, so the patient must be encouraged to eat and drink high-calorie and high-protein foods and beverages.
• Rehabilitation. The nurse should help establish and appropriate rehabilitation program for the patient during remission.

Plan meticulous, supportive care:

• Meningeal leukemia. Watch out for meningeal leukemia (confusion, lethargy, headache) and know how to manage care after intrathecal chemotherapy.
• Hyperuricemia. Prevent hyperuricemia, a possible result of rapid, chemotherapy-induced leukemia cell lysis through encouraging fluids to 2000 ml daily, giving acetazolamide and sodium bicarbonate tablets, and allopurinol.
• Infection control. Control infection by placing the patient in a private room and instituting neutropenic precautions.
• Skincare. Provide thorough skin care by keeping the patient’s skin and perianal area clean, applying mild lotions and creams to keep skin from cracking and drying, and thoroughly cleaning skin before all invasive skin procedures.
• Constipation. Prevent constipation by providing adequate hydration, a high-residue diet, stool softeners, and mild laxatives, and by encouraging walking.
• Mouth ulcers. Control mouth ulceration by checking often for obvious ulcers and gum swelling, and by providing frequent mouth care and saline rinses.
• Psychological support. Provide psychological support by establishing a trusting relationship to promote communication.
• Manage stress. Minimize stress by providing a calm, quiet atmosphere that is conducive to rest and relaxation.

Evaluation

Expected patient outcomes may include:

• Shows no evidence of infection.
• Experiences no bleeding.
• Attains optimal level of nutrition.
• Reports satisfaction with pain and comfort levels.
• Has less fatigue and increased activity.
• Copes with anxiety and grief.
• Absence of complications.

Discharge and Home Care Guidelines

Most patients cope better when they have an understanding of what is happening to them.

• Education. Based on the patient’s education, literacy level, and interest, teaching of the patient and family should focus on the disease, its treatment, and certainly the resulting significant risk of infection and bleeding.
• Vascular access device. Management of a vascular access device can be taught to most patients or family members, and the nurses may need to provide follow-up care for the patient.
• Home care services. Coordination of home care services and instruction can help alleviate anxiety about managing the patient’s care at home.

Documentation Guidelines

The focus of documentation should include:

• Recent or current antibiotic therapy.
• Signs and symptoms of infectious process.
• Individual risk factors that may potentiate blood loss.
• Baseline vital signs, mentation, urinary output, and subsequent assessments.
• Results of laboratory tests or diagnostic procedures.
• Client’s description of response to pain, specifics of pain inventory, expectations of pain management, and acceptable level of pain.
• Caloric intake.
• Individual cultural or religious restrictions and personal preferences.
• Plan of care.
• Teaching plan.
• Responses to interventions, teaching, and actions performed.
• Attainment or progress toward desired outcome.
• Modifications to plan of care.
• Discharge needs.
• Specific referrals made.

Practice Test: Acute Lymphocytic Leukemia

Here are some practice questions for this study guide. Please visit our nursing test bank page for more NCLEX practice questions.

1. Which of the following would the nurse identify as the initial priority for a child with acute lymphocytic leukemia?

A. Instituting infection control precautions.
B. Encouraging adequate intake of iron-rich foods.
C. Assisting with coping with chronic illness.
D. Administering medications via IM injections.

1. Answer: A. Instituting infection control precautions.

Acute lymphocytic leukemia (ALL) causes leukopenia, resulting in immunosuppression and increasing the risk of infection, a leading cause of death in children with ALL, therefore, the initial priority nursing intervention would be to institute infection control precautions to decrease the risk of infection.

• Option B: Iron-rich foods help with anemia, but dietary iron is not an initial intervention.
• Option C: The prognosis of ALL usually is good. However, later on, the nurse may need to assist the child and family with coping since death and dying may still be an issue in need of discussion.
• Option D: Injections should be discouraged, owing to increased risk of bleeding due to thrombocytopenia.

2. Which of the following complications are three main consequences of leukemia?

A. Bone deformities, spherocytosis, and infection.
B. Anemia, infection, and bleeding tendencies.
C. Lymphocytopoiesis, growth delays, and hirsutism.
D. Polycythemia, decreased clotting time, and infection.

2. Answer: B. Anemia, infection, and bleeding tendencies.

The three main consequences of leukemia are anemia, caused by decreased erythrocyte production; infection secondary to neutropenia; and bleeding tendencies, from decreased platelet production.

• Option A: Bone deformities don’t occur with leukemia, Although bones may become painful because of the proliferation of cells in the bone marrow. Spherocytosis refers to erythrocytes taking on a spheroid shape and isn’t a feature in leukemia.
• Option C: Mature cells aren’t produced in adequate numbers, and hirsutism and growth delay can be a result of large doses of steroids but isn’t common in leukemia.
• Option D: Anemia, not polycythemia, occurs. Clotting times would be prolonged.

3. A client with leukemia has neutropenia. Which of the following functions must be frequently assessed?

A. Blood pressure.
B. Bowel sounds.
C. Heart sounds.
D. Breath sounds.

3. Answer: D. Breath sounds.

Pneumonia, both viral and fungal, is a common cause of death in clients with neutropenia, so frequent assessment of respiratory rate and breath sounds is required.

• Options A, B, C: Although assessing blood pressure, bowel sounds, and heart sounds are important; it won’t help detect pneumonia.

4. A child is seen in the pediatrician’s office for complaints of bone and joint pain. Which of the following other assessment findings may suggest leukemia?

A. Abdominal pain.
B. Increased activity level.
C. Increased appetite.
D. Petechiae.

4. Answer: D. Petechiae.

The most frequent signs and symptoms of leukemia are a result of infiltration of the bone marrow. These include fever, pallor, fatigue, anorexia, and petechiae, along with bone and joint pain.

• Option A:  Abdominal pain may be caused by areas of inflammation from normal flora within the GI tract or any number of other causes.
• Option B: Activity level is decreased in patients with leukemia as they experience fatigue more frequently than normal.
• Option C: Increased appetite can occur but it usually isn’t a presenting symptom.

5. What are the three most important prognostic factors in determining long-term survival for children with acute leukemia?

A. Histologic type of disease, initial platelet count, and type of treatment.
B. Type of treatment and client’s sex.
C. Histologic type of disease, initial WBC count, and client’s age at diagnosis.
D. Progression of illness, WBC at the time of diagnosis, and client’s age at the time of diagnosis.

5. Answer: C. Histologic type of disease, initial WBC count, and client’s age at diagnosis.

The factor whose prognostic value is considered to be of greatest significance in determining the long-range outcome is the histologic type of leukemia.

• Option A: The platelet count is not essential in the prognosis of leukemia.
• Option B: The type of treatment and client’s sex do not necessarily affect the prognosis.
• Option D: The progression of illness does not determine the prognosis at all times.