Stem Cell Transplantation/bone Marrow Transplantation
A stem cell transplant is a medical procedure in which bone marrow that contains leukemia is destroyed and then replaced by highly specialized cells, called hematopoietic stem cells, that develop into healthy bone marrow. Hematopoietic stem cells are blood-forming cells found both in the bloodstream and in the bone marrow. These stem cells make all of the healthy cells in the blood. Today, this procedure is more commonly called a stem cell transplant, rather than bone marrow transplant, because it is the stem cells in the blood that are typically being transplanted, not the actual bone marrow tissue.
Before recommending transplantation, doctors will talk with the patient about the risks of this treatment and consider several other factors, such as the type of cancer, results of any previous treatment, and patients age and general health.
There are 2 types of stem cell transplantation depending on the source of the replacement blood stem cells: allogeneic and autologous . ALLO uses donated stem cells, while AUTO uses the patients own stem cells. However, AUTO transplants are generally not used to treat ALL. In both types, the goal is to destroy all of the cancer cells in the marrow, blood, and other parts of the body using high doses of chemotherapy and/or radiation therapy and then allow replacement blood stem cells to create healthy bone marrow.
Patients May Want To Think About Taking Part In A Clinical Trial
For some patients, taking part in a clinical trial may be the best treatment choice. Clinical trials are part of the cancer research process. Clinical trials are done to find out if new cancer treatments are safe and effective or better than the standard treatment.
Many of todays standard treatments for cancer are based on earlier clinical trials. Patients who take part in a clinical trial may receive the standard treatment or be among the first to receive a new treatment.
Patients who take part in clinical trials also help improve the way cancer will be treated in the future. Even when clinical trials do not lead to effective new treatments, they often answer important questions and help move research forward.
What Foods And Meals Are Best
People with leukemia may find that eating a healthy, balanced diet helps them stay strong during and after the treatment and boosts their ability to tolerate any side effects. The body also needs good nutrition to help it replace the blood cells and tissues that chemotherapy has damaged.
A balanced diet includes:
- plant-based oils, such as olive oil
In addition to getting plenty of the above foods, people should limit their intake of saturated and trans fats, sugar, salt, and alcohol.
It is also important to maintain hydration by drinking enough water, tea, and nonsugary drinks. Water may help alleviate chemotherapy side effects such as constipation and fatigue. It may also help people rehydrate after vomiting.
If someones symptoms include diarrhea or acid reflux, they should consider noncaffeinated beverages.
Although the food that a person eats cannot treat cancer, it can make a difference to their health and how they feel.
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Nursing Care Plan : Diagnosis Activity Intolerance
May be related to:
- Generalized weakness reduced energy stores, increased metabolic rate from massive production of leukocytes
- Imbalance between oxygen supply and demand
- Therapeutic restrictions effect of drug therapy
Possibly evidenced by:
- Abnormal HR or BP response
Desired outcomes
- Report a measurable increase in activity tolerance.
- Participate in ADLs to a level of ability.
- Demonstrate a decrease in physiological signs of intolerance e.g., pulse, respiration, and BP remain within the patients normal range.
Nursing Intervention
Independent
Evaluate reports of fatigue, noting inability to participate in activities or ADLs.
Rationale: Effects of leukemia, anemia, and chemotherapy may be cumulative , necessitating assistance.
Encourage the patient to keep a diary of daily routines and energy levels, noting activities that increase fatigue.
Rationale: Helps patient prioritize activities and arrange them around fatigue patterns.
Provide a quiet environment and uninterrupted rest periods. Encourage rest periods before meals.
Rationale: Restores energy needed for activity and cellular regeneration/tissue healing.
Implement energy-saving techniques, e.g., sitting, rather than standing, use of shower chair. Assist with ambulation/other activities as indicated.
Rationale: Maximizes available energy for self-care tasks.
Schedule meals around chemotherapy. Give oral hygiene before meals and administer antiemetics as indicated.
Rationale: May enhance intake by reducing nausea.
Leukemia May Affect Red Blood Cells White Blood Cells And Platelets
In a healthy child, the bone marrow makes blood stem cells that become mature blood cells over time. A blood stem cell may become a myeloidstem cell or a lymphoid stem cell.
A myeloid stem cell becomes one of three types of mature blood cells:
- Platelets that form blood clots to stop bleeding.
A lymphoid stem cell becomes a lymphoblast cell and then one of three types of lymphocytes :
- B lymphocytes that make antibodies to help fight infection.
- T lymphocytes that help B lymphocytes make the antibodies that help fight infection.
In a child with ALL, too many stem cells become lymphoblasts, B lymphocytes, or T lymphocytes. These cells are also called leukemia cells. These leukemia cells do not work like normal lymphocytes and are not able to fight infection very well. Also, as the number of leukemia cells increases in the blood and bone marrow, there is less room for healthy white blood cells, red blood cells, and platelets. This may lead to infection, anemia, and easy bleeding.
This summary is about acute lymphoblastic leukemia in children, adolescents, and young adults. See the following PDQ summaries for information about other types of leukemia:
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Nursing Care Plan For Leukemia 2
Nursing Diagnosis: Imbalanced Nutrition: Less than Body Requirements related to cancer disease process and/or consequences of chemotherapy for leukemia, as evidenced by abdominal cramping, stomach pain, diarrhea or constipation, bloating, unintentional weight loss, nausea and vomiting, and loss of appetite
Desired Outcome: The patient will be able to achieve a weight within his/her normal BMI range, demonstrating healthy eating patterns and choices.
Nursing Care Plan For Leukemia 1
Nursing Diagnosis: Deficient Knowledge related to new diagnosis of leukemia as evidenced by patients verbalization of I want to know more about my new diagnosis and care
Desired Outcome: At the end of the health teaching session, the patient will be able to demonstrate sufficient knowledge of leukemia and its management.
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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 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 ofbleeding 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.
D. Petechiae.
Nursing Care Of A Patient With B
Case Presentation
Chief complaint: Generalized arthralgia for 5 months.
History of present illness: A 35-year-old Hispanic man presented in November 2009 with generalized arthralgias that progressed to continuous shoulder and knee pain. Primary care physician evaluation revealed the complete blood count to be abnormal: complete blood count revealed a white cell count of 83,000/L, a hemoglobin count of 17.9 g/dL, and a platelet count of 155/L. In addition, biopsy revealed hypercellular bone marrow with involvement by a B-cell lymphoblastic leukemia. He was referred for emergent evaluation by a hematologist.
Flow cytometry revealed 80% to 90% abnormal cells expressing CD34, CD19, dim CD22, CD10, TdT, CD38, and HLA-DR, CD20. Fluorescence in situ hybridization for the Philadelphia chromosome fusion protein was negative. Full cytogenetics revealed a male karyotype with a translocation between the long arm of chromosome 1 and the short arm of chromosome 9 and addition to the long arm of chromosome 13 was observed in 6 metaphases. Five metaphases showed t unbalanced translocation between the long arm of chromosome 1 and the short arm of chromosome 19. Three metaphases showed t and dert. Six metaphases showed a normal male karyotype. The t is reported to be associated with B-cell acute lymphoblastic leukemia . Translocations resulting in partial deletion of the short arm of chromosome 9 also are reported in ALL. The final diagnosis was B-ALL.
Nursing Interventions
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Treatment Of Recurrent All
If the ALL recurs during or after treatment, the child will most likely be treated again with chemotherapy. Much of the treatment strategy depends on how soon the leukemia returns after the first treatment. If the relapse occurs after a long time, the same drugs might still be effective, so the same or similar treatment may be used to try to get the leukemia into a second remission.
If it comes back after a shorter time interval, more aggressive chemo with other drugs may be needed. The most commonly used chemo drugs are vincristine, L-asparaginase, anthracyclines , cyclophosphamide, cytarabine , and either etoposide or teniposide. The child will also receive a steroid . Intrathecal chemo will also be given.
For children whose leukemia comes back sooner after starting treatment, or for children with T-cell ALL who relapse, a stem cell transplant may be considered, especially if the child has a brother or sister who is a good tissue type match. Stem cell transplants may also be used for children who relapse after a second course of chemotherapy.
Some children have an extramedullary relapse, meaning that leukemia cells are found in one part of the body but are not detectable in the bone marrow. In addition to intensive chemotherapy as described above, children with spread to the CSF may get more intense intrathecal chemotherapy, sometimes with radiation to the brain and spinal cord . Boys with relapse in a testicle may get radiation to the area.
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 , 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.
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Typical Treatment Of Acute Lymphocytic Leukemia
in adults. To learn about ALL in children, see Leukemia in Children.)
The main treatment for acute lymphocytic leukemia in adults is typically long-term chemotherapy . In recent years, doctors have begun to use more intensive chemo regimens, which has led to more responses to treatment. But these regimens are also more likely to cause side effects, such as low white blood cell counts. Patients may need to take other drugs to help prevent or treat these side effects.
Treatment typically takes place in 3 phases:
The total treatment usually takes about 2 years, with the maintenance phase taking up most of this time. Treatment may be more or less intense, depending on the subtype of ALL and other prognostic factors.
ALL can spread to the area around the brain and spinal cord. Sometimes this has already occurred by the time ALL is first diagnosed. This spread is found when the doctor does a lumbar puncture and leukemia cells are found in the cerebrospinal fluid , the liquid that surrounds the brain and spinal cord. The treatment of this is discussed below.
Even if leukemia cells arent found in the CSF at diagnosis, its possible that they might spread there later on. This is why an important part of treatment for ALL is central nervous system prophylaxis treatment that lowers the risk of the leukemia spreading to the area around the brain or spinal cord. This is also described in more detail below.
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Nursing Care Plan For Leukemia 3
Nursing Diagnosis: Fatigue related to consequence of chemotherapy for leukemia and/or emotional distress due to the diagnosis, as evidenced by overwhelming lack of energy, verbalization of tiredness, generalized weakness, and shortness of breath upon exertion
Desired Outcome: The patient will establish adequate energy levels and will demonstrate active participation in necessary and desired activities.
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Getting Care For Symptoms And Side Effects
ALL and its treatment often cause side effects. In addition to treatments intended to slow, stop, or eliminate the disease, an important part of care is relieving a persons symptoms and the side effects of treatment. This approach is called palliative or supportive care, and it includes supporting the patient with his or her physical, emotional, and social needs.
Palliative care is any treatment that focuses on reducing symptoms, improving quality of life, and supporting patients and their families. Any person, regardless of age or type and stage of cancer, may receive palliative care. It works best when palliative care is started as early as needed in the cancer treatment process. People often receive treatment for the leukemia at the same time that they receive treatment to ease side effects. In fact, patients who receive both at the same time often have less severe symptoms, better quality of life, and report they are more satisfied with treatment.
Palliative treatments vary widely and often include medication, nutritional changes, relaxation techniques, emotional support, and other therapies. You may also receive palliative treatments similar to those meant to eliminate the leukemia, such as chemotherapy or radiation therapy. Talk with your doctor about the goals of each treatment in the treatment plan.
Treatment Of Children With Acute Lymphocytic Leukemia
The main treatment for children with acute lymphocytic leukemia is chemotherapy, which is usually given in 3 main phases:
The entire length of treatment is typically about 2 to 3 years, with the most intense treatment in the first few months.
Children with ALL are typically classified by risk group to make sure that the correct types and doses of drugs are given. Treatment may be more or less intense, depending on the risk group.
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What You Need To Know:
Acute lymphoblastic leukemia is cancer that affects the blood and bone marrow. The bone marrow makes white blood cells , red blood cells , and platelets. WBCs help fight infection. RBCs help carry oxygen throughout the body. Platelets help the blood clot. ALL causes your body to make too many immature white blood cells . These cells are cancer cells, and cannot fight infection like healthy WBCs. Cancer cells crowd the bone marrow and prevent it from making healthy blood cells. Without enough healthy blood cells, you are at risk for infection, bleeding, and anemia. Anemia is a low level of red blood cells.
Past Treatment For Cancer And Certain Genetic Conditions Affect The Risk Of Having Childhood All
Anything that increases your risk of getting a disease is called a risk factor. Having a risk factor does not mean that you will get cancer not having risk factors doesnt mean that you will not get cancer. Talk with your childs doctor if you think your child may be at risk.
Possible risk factors for ALL include the following:
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Based On The Affected White Blood Cell Type:
Encourage Use Of Soft
Page 13 PATIENT PROBLEMS PLANNING & IMPLEMENTATION EVALUATIONDATE OUTCOME ACTUAL & POTENTIAL NURSING INTERVENTION DATE COMMENTS
07.1.11 Fever related to decreased Client will have body Take client temperature every 4 hourly 12.01.2011 Client body temperature reduced to immunity temperature of 36.5 – to evaluate effectiveness of the to 37 degrees C12.1.11 37.3 C treatment e.g., PCM and antibiotic
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How Is Acute Lymphoblastic Leukemia Treated
Chemotherapy
Most kids with ALL will get chemotherapy. These are special drugs that kill cancer cells. Which drugs a child gets and in what combination depends on the subtype of ALL and how fast-moving the disease is. How cancer cells respond to the first treatment helps doctors decide how to choose the next type of chemo.
Different types of chemo can be given:
- as an injection into a muscle
- with a spinal tap right into the cerebrospinal fluid
The treatment goal is remission, which is when tests dont find any cancer cells in the body. Then, maintenance chemotherapy keeps the child in remission and prevents the cancer from coming back. Kids get maintenance chemo for 2 to 3 years.
Stem Cell Transplants
Some kids who have a fast-growing type of ALL might need a stem cell transplant . This treatment involves:
- killing cancer cells, normal bone marrow, and immune system cells with high-dose chemotherapy and/or radiation
- putting healthy donor stem cells back into the body
- rebuilding a healthy blood supply and immune system with the new stem cells
Other treatments may include:
- radiation therapy: high-energy X-rays that kill cancer cells
- targeted therapy: specific drugs that find and attack cancer cells without hurting normal cells
- immunotherapy: medicine that uses the childs own immune system to get rid of cancer cells
Clinical Trials
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