NH

 Cancer of the blood-forming tissues

 Most common form of childhood malignancy

 More males than females after age 1 year
 Peak onset 2 to 6 years
Acute – this type of leukemia entails a profound percentage of such
immature cells and tends to progress rapidly if chemotherapy is not
provided

 Acute lymphoid leukemia (ALL)

 This type of leukemia is commonly seen in children but may also
occur in adults.
 The body produces too much white blood cells that causes
infections, anemia and bleeding.
 80% of childhood cases, survivor rate 85%

 Acute myelogenous leukemia (AML) – 15-25%

 This affects the myeloid cells and grows quickly. The disease
progresses faster than other types.
 15-20% cases among children.
 Unrestricted proliferation of WBCs occur

 Bone marrow infiltration crowds out stem cells that

normally produce red blood cells and platelets;
anemia and thrombocytopenia occur; the WBCs that
are produced are immature and cannot fight
infection

 Spleen, liver and lymph nodes become infiltrated and

enlarged

 Central nervous system (CNS) is at risk for infiltration

 Clinical
manifestations are directly related to
areas of involvement, such as bone pain from
marrow proliferation
ALL AML
 Fever  Flu
 Bone pain  Bleeding
 Pallor
 bruising
 Basedon the initial WBC count at time of
diagnosis:
 More favorable if below 50,000/mm³
 Age is between 2-10 years at time of diagnosis
 If diagnosed with ALL instead of AML
 Overall prognosis has improved

 Majorityof newly diagnosed children who

receive multi-agent treatment
 Peripheral blood smear reveals anemia,
thrombocytopenia, and neutropenia

 Leukemic blasts may be seen on smear

 Bone Marrow aspiration is the definitive test

 Normal marrow contains less than 5% blasts

 Leukemic marrow has much higher percentage, often

60-100% blasts

 Spinal tap
 Achieved with a bone marrow aspirate and
biopsy.

 Typically bone marrow is taken from the iliac

crest.

 Ifbone marrow aspirate and biopsy can’t be

done may use peripheral blood if blasts are
present.
 The bone marrow aspirate is evaluated by
cell morphology, including cytochemistry;
immunophenotype; and, cytogenetics.

 Morphology describes the appearance,

structure and number of leukemic cells
present.

 Cytochemistry involves staining cells to

identify the type of cell.
 Aim of treatment is to induce a remission
(less than 5% blasts in the bone marrow)

 Chemotherapy

· Combinations of drugs are used

· Several stages

· Possible radiation therapy

 Induction

 Goal is to induce a remission

 Lasts 4-6 weeks
 Intensification or consolidation

 Serves to maintain the remission and/or further

reduce tumor burden

 CNS prophylaxis and intrathecal medication

 Lasts 2 - 3 years

 Preserves the remission

 Reinduction is used for relapses and adds drugs

not previously used

 Bone marrow transplants are considered after a

second relapse occurs
 Risk for infection

 Risk for injury

 Activity intolerance

 Anxiety

 Risk for ineffective family coping

 Pain
 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.
 Prepare
child/family for diagnostic tests and
procedures

 Relieve pain

· Opioids are titrated to the child’s needs

 Provide emotional support to child and

family
 Infection
· Private room
· Strict handwashing
· Restriction of visitors
· Adequate nutrition
· Masks
 Hemorrhage

· Platelet infusions

· Avoid skin puncture

· Meticulous mouth care

· No rectal temperatures

· Avoid activities that could cause injury

 Anemia

· Blood transfusions

 Nausea & vomiting

· Antiemetics before chemotherapy

· Anorexia

· Small, frequent feedings

· Mucosal ulceration

· Bland diet
 Soft, sponge toothbrush
· Frequent mouthwashes
· Local anesthetics
· Stool softeners
· Good body alignment, safety measures

 Alopecia
· Warn child and parents of possibility before the hair
starts to fall out
· Recommend cotton head coverings
· Reaffirm that hair will grow back

 Mood changes
 Risk for infection
 Risk for injury:bleeding
 Altered nutrition: less than body
requirements
 Risk for altered oral mucous membranes
 Altered body image related to hair loss
 Frequently monitor the client for pneumonia,
pharyngitis, esophagitis, perianal cellulitis, urinary
tract infection, and cellulitis, which are common in
leukemia and which carry significant morbidity and
mortality.

 Monitor for fever, flushed appearance, chills,

tachycardia; appearance of white patches in the
mouth; redness, swelling, heat or pain in the eyes,
ears, throat, skin, joints, abdomen, rectal and
perineal areas; cough, changes in sputum; skin rash.

 Check results of granulocyte counts. Concentrations

less than 500/mm3 put the patient at serious risk for
infection.
 Avoid
invasive procedures and trauma to skin
or mucous membrane to prevent entry of
microorganisms.

 Usethe following rectal precautions to

prevent infections:
 Avoid diarrhea and constipation, which can
irritate the rectal mucosa
 avoid the use of rectal thermometers
 keep perineal are clean.
 Care for the patient in private room with
strict handwashing practice.

 Encourageand assist patient with personal

hygiene, bathing, and oral care.

 Obtaincultures and administer

antimicrobials promptly as directed.
 Watchfor signs of minor bleeding, such as
petechiae, ecchymosis, conjunctival
hemorrhage, epistaxis, bleeding gums,
bleeding at puncture sites, vaginal spotting,
heavy menses.

 Bealert for signs of serious bleeding, such as

headache with change in responsiveness,
blurred vision, hemoptysis, hematemesis,
melena, hypotension, tachycardia, dizziness.
 Test
all urine, stool, emesis for gross and
occult blood.

 Monitor platelet counts daily.

 Administer blood components as directed.

 Keeppatient on bed rest during bleeding

episodes.
 Bone marrow transplantation (BMT) is a special
therapy for patients with cancer or other
diseases which affect the bone marrow.

 A bone marrow transplant involves taking cells

that are normally found in the bone marrow
(stem cells), filtering those cells, and giving
them back either to the patient or to another
person.

 The goal of BMT is to transfuse healthy bone

marrow cells into a person after their own
unhealthy bone marrow has been eliminated.
 Everytype of blood cell in the bone marrow
begins as a stem cell. Stem cells are
immature cells that are able to produce
other blood cells that mature and function as
needed.

 Stem cells are the most important cells

needed in a bone marrow transplant. Stem
cells, when transplanted, find their way to
the recipient's marrow and begin to
differentiate and produce all types of blood
cells that are needed by the body.
A bone marrow transplant can be used to:
 Replace diseased, non-functioning bone marrow
with healthy functioning bone marrow (for
conditions such as leukemia, aplastic anemia and
sickle cell anemia).

 Replacethe bone marrow and restore its

normal function after high doses of
chemotherapy or radiation are given to treat
a malignancy.
 This process is often called "rescue" (for diseases
such as lymphoma, neuroblastoma and breast
cancer).
 The donor is the child him/herself. Stem
cells are taken from the child either by bone
marrow harvest or apheresis (peripheral
blood stem cells) and then given back to the
child after intensive treatment.

 Often the term "rescue" is used instead of

"transplant."
 Thedonor shares the same genetic type as
the child. Stem cells are taken either by
bone marrow harvest or apheresis (peripheral
blood stem cells) from a genetically-matched
donor, usually a brother or sister.

 Otherdonors for allogeneic bone marrow

transplants include: A parent - a haploid-
identical match is when the donor is a parent
and the genetic match is at least half
identical to the recipient.
 Anidentical twin - a syngeneic transplant is
an allogeneic transplant from an identical
twin. Identical twins are considered a
complete genetic match for a marrow
transplant.

 Unrelated bone marrow transplants (UBMT or

MUD for matched unrelated donor) - the
genetically matched marrow or stem cells
are from an unrelated donor. Unrelated
donors are found through the national bone
marrow registries.
 Stem
cells are taken from an umbilical cord
immediately after delivery of an infant.

 These stem cells reproduce into mature,

functioning blood cells quicker and more
effectively than do stem cells taken from the
bone marrow of another child or adult.

 Thestem cells are tested, typed, counted

and frozen until they are ready to be
transplanted.
 Prior to the transplant, an extensive evaluation is
completed by the bone marrow transplant team.

 A complete medical history and physical examination

are performed, including multiple tests to evaluate
the child's blood and organ functions (i.e., heart,
kidney, liver, lungs).
 A child will often come into the transplant center up
to 10 days prior to transplant for hydration,
evaluation, placement of the central venous line, and
other preparations

 A suitable (tissue typed and matched) donor must be

available. Finding a matching donor can be a
challenging and lengthy process.
 Prevent from infection

 Nutritional support

 Heomodynamic monitoring

 Graft versus host disease

 giving information about disease and care
 empowering the family
 finding support outside the family, such as the
source of financial support related to treatment,
utilization of cancer foundations,
 Involvement in supporting group and others.
 Emotional – counseling, Expressions of empathy,
love, trust and caring
 Instrumental -Tangible aid and service
 Iron-deficiencyanemia is not having enough
iron in the blood. Iron is needed for
hemoglobin.

 Breastfed-onlyinfants should be given iron

beginning at 4 months of age.

 When infants are 12 months old, they should

be screened for iron-deficiency anemia.

 Ironsupplement and iron-rich foods are used

to treat iron-deficiency anemia.
 Iron supplements.
 can irritate the stomach and discolor bowel
movements. They should be taken on an empty
stomach or with orange juice to increase
absorption.

 Iron-rich diet.
 Beginningat 4 months of age, infants that
are only breastfed or partially breastfed
should be given a daily iron supplement until
they begin eating iron-rich foods.

 Infantsthat are formula-fed do not need iron

supplements. The formula has iron added to
it. Whole milk should not be given to infants
less than 12 months old.

 Infants
and toddlers from 1 to 3 years old
should have foods rich in iron.
 The term thalassemia is applied to a variety
of inherited blood disorders characterized by
deficiencies in the rate of production of
specific globin chains in hemoglobin.
 Anemia.
 Signs of anemia- unexplained fever poor feeding,
and a markedly enlarged spleen– particularly in a
child of Mediterranean extraction, are
descriptive.

 Fatigue.
 The decrease of circulating RBCs that bring about
oxygen to all parts of the body can lead to
fatigue.

 Pallor.
 Decrease in production of RBCs leads to pallor.
 Irritability.
 The child may feel irritable due to a feeling of
discomfort.

 Anorexia.
 Anorexia is apparent in a child with thalassemia.
 CBC count and peripheral blood smear.
 The CBC count and peripheral blood film
examination results are usually sufficient to
suspect the diagnosis.

 Iron studies.
 Serum iron level is elevated, with saturation
reaching as high as 80%; the serum ferritin level,
which is frequently used to monitor the status of
iron overload, is also elevated.
 Skeletal survey.
 Skeletal survey and other imaging studies reveal
classic changes of the bones that are usually
encountered in patients who are not regularly
transfused.
 ECG.
 ECG and echocardiography are performed to
monitor cardiac function.

 HLA typing.
 HLA typing is performed for patients for whom
bone marrow transplantation is considered.
 The objective of supportive therapy is to
maintain sufficient hemoglobin levels to prevent
tissue hypoxia.

 Splenectomy.
 Splenectomy is the principal surgical procedure used
for many patients with thalassemia.

 Transfusions.
 Transfusions are the foundation of medical
management; recent studies have evaluated the
benefits of maintaining the child’s hemoglobin level
above 10g/dl, a goal that may require transfusions as
often as every 2-4 weeks.
 Bone marrow transplantation.
 , either using marrow from an unaffected sibling,
or a matched, unrelated donor.

 Diet.
 A normal diet is recommended, with emphasis on
the following supplements: folic acid, small
doses of ascorbic acid (vitamin C), and alpha-
tocopherol (vitamin E); iron should not be given,
and foods rich in iron should be avoided.
 Antipyretics.Administration before blood
transfusion prevents or decreases febrile
reactions.

 Antihistamines. Administration prior to

blood transfusion may decrease or prevent
allergic reactions.

 Chelatingagents. These agents are used to

chelate excessive iron from the body in
patients with iron overload.
 Growth hormone.
 Excessive chelation with deferoxamine may
cause growth retardation; growth hormone may
be effective in increasing growth rate in all
thalassemic patient particularly the ones with
growth hormone deficiency.
 Thalassemia major.
 Assess for severe anemia, splenomegaly or
hepatomegaly with abdominal enlargement, frequent
infections, bleeding tendencies e.g. epistaxis, and
anorexia.

 Thalassemia intermediate.
 Assess for anemia, jaundice, and splenomegaly,
hemosiderosis caused by increased intestinal
absorption of iron.

 Thalassemia minor.
 Assess for mild anemia usually with no signs or
symptoms.
 Activity.
 Assist the client in planning and prioritizing activities
of daily living (ADL); assist the client in developing
a schedule for daily activity and rest; and stress the
importance of frequent rest periods.

 Health education.
 Explain the importance of the diagnostic procedures
(such as complete blood count), bone
marrow aspiration and a possible referral to a
hematologist; and explain the hematological
vocabulary and the functions of blood elements, such
as white blood cells, red blood cells, and platelets.
 Prevent infection.
 Assess for local or systemic signs of infection, such as
fever, chills, swelling, pain, and body malaise;
instruct the client to avoid contact with people with
existing infections; instruct the client to avoid eating
raw fruits and vegetables and uncooked meat; stress
the importance of daily hygiene, mouth care, and
perineal care; and teach the client and visitors the
proper hand washing.

 Prevent bleeding.
 Assess for any frank bleeding from the nose, gums,
vagina, or urinary or gastrointestinal tract and
monitor platelet count.
A mother tell the nurse on foods to
encourage her child’s diet concerning
for iron deficiency anemia; which of the
following if stated by the mother would
indicate the need for further instruction?

A. Fish
B. Lean meats
C. Whole-grain breads
D. Yellow vegetables
 Option D: If a parent states that she should
stress the intake of yellow vegetables, she
needs additional teaching because yellow
vegetables are not good source of iron.

 OptionsA, B, and C: Fish, lean meats, and

whole-grain breads are good food sources of
iron and should be supported and
encouraged.