8. Leukaemia can be classified according to pre dominent
cell type and level of cell maturity as:
lympho It means leukemia involving
the lymphoid series
Myelo It means leukemia of
myeloid (bone marrow origin)
series
9. Acute blastic It involves immature
cells
Chronic and cytic It involves mature
cells
10. PATHOPHYSIOLOGY
Proliferation of immature WBC (blast)
Competition for nutrients infiltration of organs and
replacement of normal cells by leukemia
Bone marrow reticulo CNS generalised
Dysfunction endothelial hypermetabo
system lism
13. a)Bone marrow Dsyfunction:
In alltypes of leukemia ,the proleerating
cells depress bone marrow production of
formed elements of the blood by competing
for nutrients and depriving the normal cells of
essential nutrients requered for cellular
metabolism
The main consequencu of bone
marrow dysfunction
14. Anemia due to reduced RBC
Infection due to neutropenia
Bleeding tendencies due to reduced
platelet count
Invasion of bone marrow with leukemia
cells causesthe weakening of bones
and tendency towards fracture
The most frequent presenting sign and
symptoms of leukemia occur due to
infiltration of bone marrow
15. There feature include
Fever
Pallor
Fatigue
Anorexia
Haemorrhage
Bone and joint pain
16. b) Infiltration into organs
The blood forming organs like liver, spleen and
lymph glands demonstrate marked infiltration ,
enlargement and eventually fibrosis
C) The immense metabolic needs of proliferating
leukemia cells deprive all body cells of nutrients
necessary for survival
The results is muscle wasting weight loss, anorexia and
17. CLASSIFICATION
I.ACUTE LYMPHOID LEUKEMIA;
Acute lymphoid or acute lymphocytic
leukaemia is the most commonly diagnosed
cancer in children which accounts for 80% of
all children leukaemia
Acute lymphocytic leukaemia develops
when lymphoid cell line is affected
19. Types of Acute Lymphoid leukaemia
T-cell B Cell Pre B Cell Null cell
20. a) T Cell leukaemia:
it is seen in 10-15 % cases of acute lymphocytic leukaemia
it is seen in older children ,Particulary males
Signs Symptoms :
Mediastinal mass
Hepato Spleenomegaly
High WBC Count
CNS involvement may be seen
Poor prognosis
21. b) B Cell Leukemia :
It is seen in 1-2% children will Acute lymphoid leukemia
It is an aggressive form and has poor progressive
C) Pre B Cell:
It has good prognosis and responds well to therapy
22. d) Null cell Leukemia:
The most common type of children .All occurring in 75%
cases
It has better prognosis that other types
23. II.ACUTE NON LYMPHOID /ACUTE
MYELOID LEUKEMIA
Acute non lymphocytic leukaemia is abnormal
proliferation of monocytes in bone marrow
It is present approximately 15% children with leukaemia
,It has a poor prognosis
24. TYPES OF AML:
a. Acute Mycloblastic leukaemia
b. Acute Promyclocytic leukaemia
c. Acute Myclomonocytic leukaemia
d. Acute Monocytic leukaemia
e. Acute Erythrocytic leukaemia
25. Signs Symptoms:
Recurrent chronic infection
fatigue
lymphadenomegaly
hepato Spleenomegaly
Bone or joint pain
pallor
frequent bruising
26. Gingival hypertrophy may be present
Features of CNS involvement like
Head ache
Blurred vision
Fundal haemorrhage
Paresis
Other life threatening problems like
Sluding or clumping of leukaemia cells in small cerebral
capillaries and hyperuricemia
Thrombocytopenia
27. DIAGNOSTIC EVALUATION
History and physical examination
Peripheral blood smear that contains immature
leucocytes frequently combined with low normal blood
counts
Bone marrow examination
Blood investigation reveal an
Elevated serum uric acid level due to increased turnover
of malignant cells
Radiology: done to evaluate the mediastinal mass
28. Liver and renal function test are done
To detect leukemic cells infiltration in liver and kidneys
Lumber puncture: is done to assess CNS involvement
Cyto chemical markers
Leukaemia cells demonstrate different reaction when they
are exposed to certain chemicals
29. Chromosomal Studies :
Chromosomal analysis become an important tool in the
diagnosis if ALL
For Eg:
i. Children with trisomy 21 have 15times risk of other
children for developing ALL
ii. children who are hyper diploid (more chromosoma)
have a better prognosis
30. iii. Translocation of chromosome is associated with
better prognosis
Cell surface antigens have permitted
differentiation of ALL into
3 broad classes
Non T
non B Cell (all called earley Pre B Cell)
B Cell ALL
T Cell ALL
31. Children with non T, non B ALL have the best prognosis
,especially it they have the common acute lymphocytic
leukaemia positive on their cell surface
TLC which may exceed 1,00,000/c mm with all forms of
myeloid cells and remarkable eosinophilia and basophile
32. TREATMENT
Treatment of leukaemia involve the use of
chemotherapeutic agents with or with out cranial irradiation
A) Chemotherapy :
1.Induction phase
2.Consolidation phase
3.Maintenance Therapy
33. Induction Phase:
This is the phase that reduces leukaemia cells to an
undetectable level, a state known as remission
In remission there is no evidence of leukaemia on
physical examination ,bone marrow evaluation ,pheri pheral
blood smear ,CSF examination or examination of other extra
medullary sites.
34. 95% children with leukaemia achieve remission during
induction within 4 weeks
Drugs used for induction in ALL are:
Prednisolone
Vincristine
L-asparaginase with or with out doxorilbicin
In AML for induction drugs are
eyrarabine (era-c)
daunorubicin
35. Leukaemia cells can cross the blood brain barriers while
most chemotherapy drugs ,do not cross this barriers
Children with ALL receive CNS prophylaxis with
chemotherapy drugs instilled during LP
Children who present with CNS disease also need
radiation therapy
36. Consolidation phase/Intensification:
The rent phase of treatment is consolidation or
intensification that aims at eradicating any residual
leukaemia cells
This phase of therapy begins onc remission is attained
treatment is directed at those anatomic sites which are
protected to some extent from systemic chemotherapy like
CNS
(protected by blood brain barriers ) and testes that lie outside
the body.
37. This phase involves prophylactic treatment of CNS with
cranial irradiation or intrathecal administration of
methotrexate
methotrexate:
This therapy usually conists of daily high dose
radiation treatment for about 2 weeks or twice a week doses
of methotrexate , a total of 5-6 injections
38. 3. Maintenance therapy:
Aims at preventing recurrence or further reducing the
number of leukemic cells
maintenance therapy begins after successful completion
of induction and consolidation phase
Drugs frequently used in maintenance therapy are 6
macaptopurm and weekly doses of oral methorexate
39. During this phase weekly or monthly complete blood
count is done to evaluate marrow s response to drugs
If WBC counts gas below 2000/mm3 or toxic side
effects occur than therapy is temporarily stopped or dose is
reduced
40. B. Bone marrow transplantation :
Bone marrow transplants have been used successfully in
treating some children wit ALL and ANL
In general bone marrow transplant is not recommended for
children with ALL because of excellent results possible with
chemotherapy
marrow transplant is possible only when suitable donor is
available
Prognosis:
After transplantation depends on type of leukaemia
Long term survival after marrow transplant is seen in 25% -
50% cares
41. Nursing management
a) Management of problems of leukaemia
Management of anaemia:
• Nurses should assess the leukaemia children for anaemia
and its severity
• Blood transfusion with packed red cells may be required to
raise Hb level above 10gm /dl
• Nurses should take all precaution to prevent problems
associated with blood transfusion like
42. Transmission of blood borne infection to the patient to
the patient through transfusion of contaminated blood
,transfusion reaction etc.
Prevention from infection:
broad spectrum antibiotics
live vaccine
universal precaution
isolation
43. barriers Nursing
strict hand washing
aseptic techniques
Fever is a sign of infection ,so it fever occurs
blood ,urine , stool and nasopharyngeal cultures are
done to identify the cause and site of infection
44. Adequate protein and calories intake provides the child
with better host defence against infection and increase
tolerance to chemotherapy
3.Prevention and management of haemorrhage
administer platelets
Regular mouth care
Use soft tooth brush
The children develop repeated episodes of diarrhoea, so
they prone to rectal ulceration
During bleeding episodes ,the parents and child need
45. B) Management of side effects of chemotherapy and
problems of irradiation
Nausea and Vomiting
Antemitics promethezine
chlorpromazine
Metaclopramole
Severe vomiting
46. Anorexia :
Small and frequent feed
Soft and early digestible food
Serve the food attractive manner
Mucoal ulceration:
Give bland ,moist and soft diet to the child
Use soft brust on cotton tipped application and mouth wash
Frequent mouth wash with normal saline
47. Local anaesthetics
Liberal fluid intake
Nasogastric feeds
Neuropathy
Vincristine ,vinblastine
The child suffer from constipation
Hemorrhagic cystitis
Alopecia
48. The drugs cyclophosphamide leads to haemorrhage cystitis
.It can be presented by
liberal fluid intake
motivate the child to void immediately on feeding the
urge to urinate
administered chemotherapy drugs in the morning
,to allow for sufficient intake of oral fluids
49. Mood changes
Shortly after starting of steroid therapy, children
experience mood change with range from feeling of well
being and euphoria depression and irritability
Parental support and guidance
Nurses should coutinually guide support and help
parents to adjust to this disease condition
50. parents should be encouraged to express their feelings,
fear , grief and concerns
Provide emotional support to the parents continuouslyas
51. NURSING DIAGNOSIS
High risk for injury physiologic due to bone marrow
suppression ,infection associated with the proliferature
production of beta cells and the resultant disease in
normal levels of mature blood cells
High risk for impaired skin integrity, alteration in oral
mucosa , risk factors the effets of cytotoxic drugs or
rapidly dividing mucosal cells
52. Altered nutrition less than body requirement rlt dysphagia
associated with stomatitis ,anorexia associated with
nausea and vomiting
Fluid volume and electrolytic deficit rlt to inadequate fluid
intake associated with stomatitis ,anorexia or nausea
caused by chemotherapy
53. Fear and anxiety rlt perception about diagnosis of a life
threatening procedure, hospital environment
Disturbance in body image self esteem disturbance
altered role performance personal identify disturbance rlt
child and family perception regarding
