Leukemia: White Blood Cell Disorders

• Disruptions in white blood cell production, maturation, or proliferation can lead to pathological conditions.
• Leukemia is a serious, progressive condition often resulting in death from anemia, hemorrhage, or intermittent infection.
• It affects all age groups, but it is primarily considered a childhood disease.

Definition

• Leukemia is an uncontrolled proliferation of abnormal white blood cells, leading to cellular destruction due to infiltration of leukemic cells.
• It is characterized by an excessive, uncontrolled production of leukocytes in blast form.
• Leukocytes are immature and unable to perform their normal functions.
• Uncontrolled proliferation of white blood cells is seen in the liver, spleen, and lymph nodes.
• Normal marrow elements are replaced by the accumulation of white blood cells in the bone marrow.

Causes and Classification

• Leukemia is classified based on the type of cell involved and the maturity of malignant cells.
• Based on the cell line involved, it is classified into two types: acute or chronic.
• Lymphocytic or lymphoblastic leukemia is one type.
• Myelocytic or myeloid or non-lymphocytic leukemia is another type.
• When cells are immature, it is referred to as acute leukemia.
• When cells are differentiated, it is referred to as chronic leukemia.
• The exact cause of leukemia is unknown, but it is associated with factors like chromosomal abnormalities (e.g., Down's syndrome).
• Chronic bone marrow dysfunction (e.g., aplastic anemia) is a factor.
• Infectious agents, such as viruses, may contribute.
• Chemical agents like benzene may be involved.
• Exposure to radiation is a risk factor.
• Immunodeficiency can play a role.
• Cytotoxic drug therapy can be a factor.

Pathophysiology

• Leukemia involves uncontrolled proliferation of immature cells (blasts) in the bone marrow and peripheral tissue.
• Immature cells suppress the proliferation of normal cells, leading to severe anemia.
• Thrombocytopenia (hemorrhage) and granulocytopenia (increased susceptibility to infection) leads to reduced immunity.
• The onset of leukemia is usually insidious, with insufficient production of normal blood cells.
• Acute leukemia onset often coincides with an acute upper respiratory tract infection with 'flu'-like symptoms and fatigue.
• There is an increased metabolic rate due to rapid cell proliferation and death, accompanied by fever, tachycardia, decreased heat tolerance, and weight loss.
• Dysfunction in the bone marrow results in decreased production of RBCs and platelets, leading to anemia and thrombocytopenia.
• Anemia is manifested by pallor, shortness of breath, weakness, and palpitation.
• Internal and external bleeding occurs due to decreased production of thrombocytes, manifested by bleeding of the gums, epistaxis, melena, etc.
• Proliferation of leukemia cells within organs leads to enlargement of the liver and spleen and expansion of bone marrow, resulting in pain in these areas and lymphadenopathy.
• In later stages, the kidneys may be infiltrated by leukemia cells, causing renal insufficiency.
• Headache and vomiting may be present due to meningeal irritation, which occurs commonly in lymphocytic leukemia.
• While there are increased leukocytes, they are immature and cannot effectively migrate to areas of inflammation, phagocytose, or destroy bacteria which leads to increased susceptibility to infection.

Clinical Manifestations

• Fever
• Malaise
• Tachycardia
• Weight loss
• Shortness of breath
• Epistaxis
• Hepatosplenomegaly
• Abdominal pain
• Vomiting
• Prolonged clotting time
• Bleeding gums
• Splenomegaly
• Bone and joint pain

Diagnostic Evaluation

• Decreased RBC and platelet count
• Bone marrow specimen reveals numerous immature cells (blasts)
• WBC increase reflects leukocytosis (in blast form)
• Lumbar puncture identifies the presence of leukemic cells in CSF

Management

• Directed towards suppressing leukemic cells, preventing complications, and supporting the patient physically, biologically, and psychologically.
• Benefits of antineoplastic agents must be weighed against the chances of success and possible side effects.
• Specific drug therapy is designed to eliminate leukemic tissue and allow the recovery of normal hematopoietic cells.
• Vincristine and prednisone/prednisolone are beneficial in acute lymphoblastic leukemia.
• Acute myeloblastic leukemia responds mainly to daunorubicin, cytarabine, and mercaptopurine/thioguanine.
• These drugs are toxic to normal tissues, causing severe depression, profound bleeding, and increased susceptibility to infection due to thrombocytopenia and neutropenia.
• Radiotherapy may be employed alongside the drugs.
• Transfusion of red cell concentrate maintains hemoglobin levels; Platelet transfusions correct thrombocytopenia.
• Antibiotics, such as aminoglycosides, treat infections.
• Analgesics help alleviate pain.
• Surgical bone marrow transplants can be performed in severe cases.

Nursing Care

• Non-spicy, bland meals are high in calories, vitamins, and proteins, given in small, frequent feedings to maintain nutrition.
• Adequate fluid intake helps prevent renal stone formation because of increased uric acid levels from massive cell destruction.
• Avoid trauma or intramuscular injections, and avoid drugs like aspirin.
• Patients should be discouraged from using sharing sharp objects, maintain short nails.
• Patients should be observed for bleeding, Elevated body temperature reported, and dyspnea observed.
• Also observed signs related to medications.
• Frequent oral hygiene prevents oral lesions, and daily baths reduce skin flora.
• Gloves should be worn to start Infusions. Sites cleaned and Changed.

Complications

• Anemia
• Increased susceptibility to infection
• Renal insufficiency
• Septicemia.
• Thrombocytopenia
• Hemorrhage

Nursing Diagnoses

• Ineffective tissue perfusion, related to suppression of normal blood cells evidenced by pallor.
• Pain (bone & joints), related to pressure from rapidly proliferating cells in the bone marrow evidenced by patient complaints.
• Risk for infection related to immune suppression.