Chapter 49 Leukemia, Childhood
PATHOPHYSIOLOGY
Leukemia is a cancer of the hematapoietic tissues that produce white blood cells (leukocytes). In normal blood cell development, the undifferentiated puripotent stem cells in the bone marrow proliferate and differentiate into one of two cell lines: myeloid or lymphoid cells. Myeloid cells differentiate and mature into red blood cells, monocytes, granulocytes, and platelets. Lymphoid cells differentiate and mature into T and B cells. In leukemia, normal hematopoiesis is interrupted, and the cells are unable to differentiate and mature into the various functioning white cells. In acute leukemias of childhood, the leukemic cells infiltrate the bone marrow, displacing the normal cellular elements and resulting in anemia, thrombocytopenia, and leukopenia. Leukemic cells may also infiltrate lymph nodes, the spleen, the liver, bones, and the central nervous system (CNS), as well as the reproductive organs. Leukemic infiltrates of the skin called chloromas or granulocytic sarcomas are found in some affected children.
The classification of childhood leukemia is based on the predominant cell line that is affected. Acute lymphocytic leukemia (ALL) affects the lymphoid cell lines and is classified into acute T- and B-cell leukemia subtypes. Acute myelogenous leukemia (AML) affects any of the myeloid cell lines, such as in acute monoblastic, myeloblastic, promyelocytic, and myelocytic leukemias. Chronic leukemia is more commonly seen in adults; less than 5% of leukemia in children is chronic (chronic myleogneous leukemia and chronic lymphocytic leukemia). Acute leukemia is a rapidly progressing disease involving mostly immature, undifferentiated cells, as opposed to the chronic leukemias, which are more insidious in onset.
INCIDENCE
Acute Lymphocytic Leukemia (ALL)
1. Leukemia is the most common type of childhood cancer and accounts for approximately one fourth of all childhood cancers.
2. ALL accounts for 75% to 80% of all cases of childhood leukemia.
3. Highest incidence is in children between the ages of 2 and 5 years, with peak between 2 and 3 years of age.
4. ALL is most common in males and whites.
5. Females have a better prognosis overall than males.
6. For acute lymphocytic leukemia, 5-year survival rates exceed 80%, which is a dramatic improvement for a disease that was virtually incurable in the 1960s.
7. African Americans have less frequent remissions and a lower median survival rate.
8. Risk of the disease increases for children with Down syndrome.
Acute Myelogenous Leukemia (AML)
1. AML incidence is constant from birth to 10 years and then peaks slightly in adolescence.
2. Leukemia in infancy is more commonly AML than ALL.
3. AML accounts for 20% to 25% of all cases of childhood leukemia, and the ratio of ALL to AML incidence is 1:4.
4. Boys and girls are equally affected by the disease.
5. It is more difficult to induce remission in children with AML than in those with ALL (70% remission rate).
6. Five-year survival rates have increased from less than 5% in the 1970s to 43% today as a result of treatment intensification, bone marrow transplantation, and enhanced supportive care.
7. Risk of the disease increases for children with congenital conditions such as Down syndrome.
CLINICAL MANIFESTATIONS
COMPLICATIONS
ALL
1. CNS: increased intracranial pressure, seizures secondary to meningeal infiltration; muscle cramping and weakness due to electrolyte imbalance; stroke secondary to high white blood count, causing hyperviscosity of blood and cerebral vessels
2. Head, ears, eyes, nose, and throat (HEENT): recurrent sore throats and ear infections secondary to immunosuppression; bleeding gums and gingiva due to low platelet count; lymphadenopathy due to disease process
3. Skin: pallor, leukemia cutis, petechiae, bruising
4. Cardiovascular: tachycardia and cardiac failure secondary to profound anemia; fever, hypotension, septic shock secondary to infection/immunosuppression
5. Pulmonary: mediastinal mass causing respiratory compromise (T-cell ALL)
6. GI: abdominal distention due to hepatosplenomegaly; typhlitis secondary to immune suppression; GI bleeding due to low platelet count
7. Genitourinary: testicular swelling and pain secondary to leukemic infiltration
8. Musculoskeletal: bone pain due to bone marrow infiltration of leukemia
LABORATORY AND DIAGNOSTIC TESTS
1. Complete blood count—children with white blood cell (WBC) count of less than 10,000/mm3 at time of diagnosis have best prognosis; WBC count of more than 50,000/mm3 is an unfavorable prognostic sign in children of any age. Low hemoglobin level and hematocrit indicate anemia. Low platelet count indicates potential for bleeding.
2. Lumbar puncture—to assess CNS involvement
3. Chest radiographic study—to assess for presence of a mediastinal mass
4. Bone marrow aspiration study—to determine the morphologic appearance, structure, and percentage of leukemic cells present in the bone marrow. A finding of greater than 25% blast cells confirms the diagnosis of leukemia.
5. Immunophenotyping of bone marrow cells—to determine the cell lineage and stage of differentiation of the cells
6. Cytogenetic testing of bone marrow cells—to assess for any abnormalities in the number of chromosomes (ploidy) and presence of changes in the chromosome structure of the leukemic cells, such as translocations. This testing provides important information for the risk classification of the leukemia and helps to assign the patient to an appropriate therapy. Hyperdiploidy is considered a good prognostic indicator in that hypodiploidy is a high-risk feature.
7. PT, PTT, fibrinogen—to assess for clotting defects or the presence of DIC
8. Metabolic profile to include blood urea nitrogen (BUN), creatinine, potassium, calcium, phosphorus, and uric acid—to assess for tumor lysis syndrome. The rapid release of intracellular metabolites from the leukemic cells when destroyed by chemotherapy can cause significant electrolyte imbalance and renal compromise.
9. Serum lactate dehydrogenase (LDH)—used as an indicator of rapid cell turnover/destruction
10. Echocardiogram, electrocardiogram (ECG)—to assess cardiac function before the initiation of therapy that may affect heart contractility
MEDICAL MANAGEMENT
Chemotherapy protocols vary according to the type and risk category of the leukemia. Age of patient, white cell count at diagnosis, cell type of leukemia, presence of cytogenetic abnormalities, and response to induction therapy all determine the risk category and intensity of treatment the child will receive. Chemotherapeutic agents are administered to prevent cancer cells from dividing and metastasizing. The mix of chemotherapeutic agents used in the protocols to treat leukemia is effective because they attack rapidly dividing cells in the different phases of cell division, optimizing cell kill. It is also because of this action on the normal rapidly dividing cells (such as in the bone marrow, the mucous membranes, and hair follicles) as well as on the leukemia cells that most of the side effects from therapy are seen.
The process of inducing remission in children with leukemia consists of three phases: induction, consolidation, and maintenance therapy, with CNS sanctuary therapy included and essential to each phase. During the induction phase (lasting for approximately 4 to 6 weeks), the child receives a variety of chemotherapeutic agents to induce remission from disease. Remission is considered to occur when there is no evidence of leukemia cells in peripheral blood, there are less than 5% blasts in the bone marrow and no evidence of CNS disease, and all cell lines have recovered from the induction therapy. Intensification therapy, known as consolidation, follows induction and is designed to strengthen the remission achieved in induction and to further reduce the leukemic burden before the emergence of drug resistance. The duration of consolidation and the intensity and choice of agents vary. Maintenance therapy is administered following consolidation and is designed to provide a sustained continuation therapy to eliminate all residual leukemic cells. Chemotherapy treatment protocols are approximately 2 to 3 years in duration for ALL and 6 to 9 months for AML. AML patients receive induction and consolidation therapy only. Chemotherapy agents used to treat childhood leukemias include but are not limited to steroids, vincristine, asparaginase, methotrexate, mercaptopurine, cytarabine, cyclophosphamide, etoposide, mitoxantrone, and daunorubicin. Other important supportive care drugs used during chemotherapy include allopurinol, leucovorin, and mesna.
Prednisone and Dexamethasone
Prednisone and dexamethasone (Decadron) have a direct lytic action on leukemia cells. They also inhibit tumor proliferation by blocking naturally occurring substances that stimulate tumor growth. Decadron is more commonly used in current therapies for leukemia since studies suggest it may be more efficient in crossing the blood-brain barrier. Dexamethasone is also used with antiemetics in acute cases of nausea to potentiate the effect of the antiemetic, increasing its ability to penetrate to the chemoreceptor zone of the brain. Possible side effects are the following:
1. Fluid and electrolyte disturbances—sodium retention, fluid retention, congestive heart failure in susceptible clients, potassium loss, hypertension
2. Musculoskeletal effects—bone pain, muscle weakness, osteoporosis, pathologic fracture of long bones, avascular necrosis of the hips in prolonged use
3. GI effects—gastritis and/or esophagitis, gastric ulceration, pancreatitis, abdominal distention, increased appetite, weight gain
4. Dermatologic effects—impaired wound healing, petechiae and ecchymoses, facial erythema, hirsutism, acne hypopigmentation or hyperpigmentation, striae with weight gain
5. Neurologic effects—leukoencephalopathy, raised intraocular pressure, convulsions, vertigo, headache, irritability, mood swings, psychosis
6. Endocrine effects—Cushing’s syndrome, pituitary-adrenal axis suppression, manifestations of latent diabetes mellitus
7. Ophthalmic effects—posterior subcapsular cataracts
8. Metabolic effects—negative nitrogen balance resulting from protein catabolism
9. Immune suppression—elevated white blood cell count, increased risk of infection
Dosage is individualized based on child’s body surface area and the treatment protocol and severity of the disease. Children usually receive a month of steroid therapy during induction and later receive 1- to 2-week pulses at different phases of their therapy. It is an essential part of the therapy plan. Supportive care to treat the side effects of the steroid therapy is often needed. The drug is administered by mouth (PO), with food to decrease the GI upset and commonly in conjunction with an H2 inhibitor to decrease the risk for gastritis. If the child is unable to take oral medications, the dose will be administered by intravenous (IV) route. It is added to intrathecal chemotherapy per protocol.
Vincristine (Oncovin)
Vincristine is an antineoplastic agent that inhibits cell division during metaphase. Possible side effects are the following:
1. Neuromuscular effects—peripheral neuropathy, paresthesias, numbness, loss of deep tendon reflexes, jaw pain, extraocular muscle paralysis, ptosis, vocal cord paralysis
2. Dermatologic effects—alopecia, tissue damage secondary to extravasation
3. GI effects—stomatitis, anorexia, nausea, vomiting, diarrhea, constipation, paralytic ileus
4. Hematologic—myelosuppression
5. Other effects—hypersensitivity, hyponatremia, syndrome of inappropriate antidiuretic hormone secretion (SIADH)
Refer to treatment protocol for dosage. Vincristine is administered by IV push, ideally via a central venous access device to reduce the risk of extravasation, which may cause severe tissue damage and necrosis. There must be a blood return before administration of drug. Prophylactic stool softeners are given to children receiving this drug. Dose modifications are required if evidence of significant peripheral neuropathy develops.
Asparaginase (Elspar)
Asparaginase decreases the level of asparagine (an amino acid necessary for tumor growth). It is used in the treatment of ALL. It is made from an Escherichia coli enzyme, and if a patient develops allergies to this enzyme, it is changed to another enzyme form called Erwinia asparaginase. Asparaginase is also used for the treatment of acute lymphocytic leukemia in a pegylated (slow-release) form called PEG-asparaginase. Possible side effects are the following:
1. Allergic manifestations—most serious side effects of asparaginase are the following:
2. Coagulopathy—low fibrinogen, thrombosis
3. Liver toxicity—jaundice, hypoalbuminemia, coagulation abnormalities
4. Pancreatitis—elevated amylase and/or lipase, hyperglycemia
5. Neurologic—rare cases of CNS ischemic attacks, somnolence, convulsions
Refer to treatment protocol for dosage. It is administered intramuscularly (IM). PEG-asparaginase is commonly split into two injections because of its volume.
Methotrexate (Amethopterin, MTX)
Methotrexate is classified as an antimetabolite. It interferes with folic acid metabolism. Folic acid is essential to the synthesis of the nucleoproteins required by rapidly multiplying cells. Methotrexate is used in the treatment of ALL.
Methotrexate is given in many different forms and used in all phases of ALL therapy. It can be given by the oral, IM, IV, or intrathecal routes. Vitamins containing folic acid must be avoided to prevent the metabolic block caused by methotrexate. Possible side effects are the following:
1. Skin reactions—generalized erythematous rash, urticaria, acne, pruritus, peeling, folliculitis
3. Oral and GI tract ulcerations
9. Photosensitivity and/or hyperpigmentation
10. CNS deterioration: learning problems, seizures, somnolences, leukoencephalopathy
When intermediate- or high-dose methotrexate is given by IV route, a rescue agent called leucovorin is administered at timed intervals. Hydration and alkalinization fluids are run concurrently to prevent renal damage and to enable renal clearance of the methotrexate in a safe interval of time. Additional bone marrow-suppressive medications such as Bactrim are held when methotrexate is being administered. Patients are educated to avoid the sun and to wear sunblock when taking methotrexate, since even low doses can result in severe cases of sunburn with sun exposure.
Mercaptopurine (Purinethol, 6-MP)
Mercaptopurine interferes with the synthesis of nucleic acid, which is especially needed when cells are growing and multiplying rapidly. The primary effects of mercaptopurine occur in tissues with rapid cellular growth and a high rate of nucleic metabolism (e.g., bone marrow and gastric epithelium). Leukocyte, thrombocyte, and reticulocyte formation is reduced. The drug is used in the treatment of ALL and may be given by IV route or PO. Possible side effects are the following:
Refer to treatment protocol for dosage. When given orally, it is taken daily at least 2 hours after eating on an empty stomach.
Thioguanine (6-TG)
Thioguanine interferes with cell metabolism by inhibiting purine syntheses. It is given orally on a daily basis for 2-week periods in cycles of ALL therapy. Potential side effects include the following:
2. Anorexia, nausea, and vomiting
5. Hepatic fibrosis, hyperbilirubinemia
6. Allergic reaction; urticaria; anaphylaxis (in rare instances)
Refer to the treatment protocol for specific dosage. Similar to oral mercaptopurine, this drug is given on an empty stomach 2 hours after the evening meal.
Cytarabine (ARA-C, Cytosine Arabinoside, Cytosar)
Cytarabine is a cell cycle–specific drug that inhibits cell development in the G1 to S phases of cell division. It is currently indicated for induction of remission in individuals with AML and ALL and is used in consolidation therapy for ALL. Cytarabine is a potent bone marrow suppressant and also has penetration into the CNS; therefore intrathecal chemotherapy is not given concurrently with this drug. Individuals receiving this drug must be under close medical supervision and, during induction therapy, should have leukocyte and platelet counts performed frequently. It is highly emetogenic at high doses. Possible side effects are the following:
1. Anorexia, nausea, and vomiting
3. Flulike symptoms: fever, chills, arthralgias
8. CNS: cerebellar dysfunction, encephalopathy, seizures, paresis, learning disabilities
Cytarabine may be given by IV, subcutaneous, or intrathecal route. It is a highly emetogenic drug and necessitates that antinausea medications be given before administration of the drug and continuously or at intervals afterward. Dexamethasone ophthalmic drops are administered every 2 to 3 hours with high-dose cytarabine and for 5 days following administration to reduce the risk of conjunctivitis. Tylenol is given for fevers related to the flulike symptoms associated with the drug, and care must be taken to monitor carefully for signs and symptoms of infection as a source of fever in an immune-suppressed child.
Cyclophosphamide (Cytoxan)
Cyclophosphamide is a nitrogen mustard derivative that acts as an alkylating agent by interfering with DNA replication and transcription of RNA in cell division. Cyclophosphamide is used in the treatment of ALL and AML. Possible side effects are the following:
3. Alopecia (occurs in at least 50% of individuals)
4. Leukopenia (decreased WBCs)
b. Ordinarily serves as guide to therapy
c. Leaves child susceptible to bacterial infection
5. Sterile hemorrhagic cystitis (active mustard derivatives excreted in the urine cause bladder mucosal irritation and/or bladder fibrosis)
7. Cardiotoxicity at high doses
8. Hyponatremia (due to SIADH) and hypokalemia
Cyclophosphamide is administered by IV route or PO. Administration of high doses of cyclophosphamide should be preceded by IV fluid administration to help irrigate the bladder, and a protective drug called mesna is often given at timed intervals with the cyclophosphamide since it binds to the breakdown products of cyclophosphamide in the bladder and reduces the risk of hemorrhagic cystitis. Children receiving cyclophosphamide should empty their bladder frequently, and it is ideally given during daytime hours to promote compliance with voiding and to prevent toxic metabolites accumulating in the bladder at night. Urine is monitored for hematuria, and additional fluids may be ordered if urine output decreases and evidence of blood in the urine appears.
Daunorubicin (Daunomycin, DNR)
Daunorubicin inhibits the synthesis of DNA. It is used to inhibit cell division in treatment of acute leukemias. It has antimitotic and immune-suppressive properties. Possible side effects are the following:
1. Sclerosing of vein (if given via peripheral IV)
4. Cardiac arrhythmia, cardiomyopathy (cumulative and dose-dependent, affecting contractility of cardiac muscle)
5. Elevated liver enzyme levels (elevated serum glutamate pyruvate transaminase [SGPT], elevated serum glutamic-oxaloacetic transaminase [SGOT])
6. Change in urine color to red
7. Radiation recall (skin erythema, rash, and exfoliation if given with radiation therapy)
Mitoxantrone (Novantrone)
Mitoxantrone interacts with DNA and inhibits the enzyme topoisomerase, causing cell lysis. It is used in the treatment of AML. It is administered via IV infusion and preferably via a central venous line, since it causes local ulceration and tissue necrosis if extravasation occurs. Potential side effects include the following:
1. Cardiac arrythmias, cardiomyopathy (dose-dependent)
This drug is not given if maximum cumulative doses of other cardiotoxic drugs have been given, and must be used with caution in patients who have received mediastinal or mantle radiation therapy or who have a cardiac condition.
Etoposide (VP-16, VePesid)
Etoposide is a plant alkaloid that inhibits DNA synthesis so that cells do not enter mitosis; it therefore prevents cell division. It is used in the treatment of AML and recurrent or refractory ALL. It is given by IV route and is available orally for use with other cancers. It is routinely given as a 1-hour infusion with careful monitoring of the patient during the infusion. Potential side effects include the following:
5. Hypotension (during infusion)
6. Peripheral neuropathy, constipation
Blood pressure measurements are routinely monitored every 15 minutes during etoposide infusion. IV infusions must not be diluted to concentrations greater than 0.4 mg/ml since the drug becomes unstable.
Allopurinol (Zyloprim)
Allopurinol inhibits the production of uric acid by blocking the biochemical reactions that immediately precede uric acid formation. The result is a lowering of blood and urinary uric acid levels. The drug is given prophylactically to prevent tissue urate deposits or renal calculi in children with leukemia who are receiving chemotherapy that results in the elevation of serum uric acid levels. Allopurinol also inhibits the oxidation of mercaptopurine, so that smaller doses of mercaptopurine are required (one fourth to one third of the regular dose). Possible side effects are the following:
Allopurinol is administered orally (it can be given by IV route during the induction phase if the child is unable to ingest the PO form). IV hydration is administered at least twice the maintenance amount and is given along with alkalinization therapy to prevent renal uropathy. Refer to treatment protocol for dosage.
Raspuricase (Elitek)
Raspuricase is a relatively new drug used in malignancies where there is a high tumor burden, such as acute leukemias and lymphomas. It converts uric acid to allantoin, an inactive and soluble metabolite readily excreted by the kidneys. It is administered by IV route before the first dose of chemotherapy and may be continued on a daily basis until the risk of tumor lysis and renal uropathy resolves. Raspuricase acts rapidly and works in the prevention and treatment of chemotherapy-induced hyperuricemia in children with leukemia who have a high cell turnover, to reduce the risk of an oncologic emergency and irreversible renal damage. Potential side effects include the following:
NURSING ASSESSMENT
1. See the Cardiovascular Assessment, Respiratory Assessment, and Neurologic Assessment sections in Appendix A.
2. Assess child’s reaction to chemotherapy.
3. Assess for signs and symptoms of infection.
4. Assess for signs and symptoms of bleeding.
5. Assess for signs and symptoms of anemia.
6. Assess for signs and symptoms of complications related to therapy: radiation somnolence, CNS symptoms, tumor lysis, renal uropathy.
7. Assess child’s and family’s understanding of diagnosis and therapy plan, and coping ability.
NURSING DIAGNOSES
NURSING INTERVENTIONS
1. Monitor child for reactions to medications (Table 49-1).
2. Monitor for signs and symptoms of infection.
3. Monitor for signs and symptoms of bleeding.
4. Monitor for signs and symptoms of anemia.
5. Monitor for signs and symptoms of complications (refer to side-effects in the earlier Chemotherapy sections).
6. Monitor for concerns and anxiety about diagnosis of cancer and its related treatments; monitor for emotional responses such as anger, denial, and grief (see the Supportive Care section in Appendix F).
7. Support involvement in age-appropriate activities as tolerated.
8. Monitor disruptions in family functioning.
Table 49-1 Nursing Interventions Related to the Child Undergoing Chemotherapy and Radiotherapy
| Responses | Nursing Interventions |
|---|---|
| Diarrhea | Offer oral fluids frequently. |
| Perform skin care to buttocks and perineal area. | |
| Apply barrier cream to prevent further skin breakdown. | |
| Monitor effectiveness of antidiarrheal medications. | |
| Avoid high-cellulose foods and fruit. | |
| Offer small, frequent feedings; include child’s favorite foods if possible. | |
| Observe for signs of dehydration. | |
| Monitor IV infusions. | |
| Anorexia | Monitor intake and output. |
| Offer small, frequent feedings of any bland foods high in nutrients and calories. | |
| Consult with child and parents to develop meal plan that incorporates child’s likes and dislikes. | |
| Maintain adequate fluid intake, using Popsicles, ice cream, gelatin, and noncarbonated beverages. | |
| Obtain weight daily. | |
| Nausea and vomiting | Avoid noxious smells that may increase nausea and vomiting. |
| Observe for dehydration. | |
| Monitor side effects of antiemetics (e.g., ondansetron [Zofran], gransetron [Kytril], promethazine HCl [Phenergan], diphenhydramine HCl [Benadryl]) and lorazepam [Ativan]). | |
| Fluid retention | Monitor intake and output. |
| Obtain weight daily. | |
| Evaluate for respiratory distress and edema. | |
| Provide frequent changes of position. | |
| Monitor side effects of diuretics. | |
| Hyperuricemia | Monitor intake and output. |
| Encourage fluid intake. | |
| Monitor IV hydration and alkalinization. | |
| Provide skin care to decrease itching. | |
| Monitor serum creatinine and uric acid levels. | |
| Monitor side effects of allopurinol. | |
| Monitor side effects of raspuricase. | |
| Chills and fever | Monitor vital signs and frequency of symptoms. |
| Evaluate source of symptoms (e.g., tumor or infection). | |
| Monitor side effects of antipyretics. | |
| Provide comfort measures such as blankets and tepid sponge baths. | |
| Stomatitis and mouth ulcers | Provide antibacterial mouthwashes routinely. |
| Administer pain medication to control mouth pain. | |
| Give topical mouthwashes such as Benadryl or Maalox to soothe the mucosal irritation. | |
| Avoid hard-bristled toothbrushes. | |
| Avoid glycerin swabs and alcohol-based mouthwashes. | |
| Avoid hard foods that require excessive chewing and foods that are acidic or spicy. | |
| Avoid hot foods. | |
| Cardiotoxicity (doxorubicin and daunorubicin) | Monitor changes in ECG and vital signs. |
| Observe for signs and symptoms of congestive heart failure. | |
| Hemorrhagic cystitis | Encourage frequent voiding after drug administration (cyclophosphamide). |
| Offer oral fluids in large amounts. | |
| Monitor IV fluids. | |
| Encourage voiding before sleep. | |
| Alopecia | Prepare child and family for hair loss. |
| Reassure child and family that hair loss is temporary. | |
| Prepare child and family for hair regrowth that differs in color and texture from former hair. | |
| Arrange for another child in same developmental stage to visit child and talk about the experience. | |
| Suggest use of scarf, hat, or wig before hair loss as transition measure. | |
| Pain | Evaluate child’s verbal and nonverbal behavior for evidence of pain. |
| Note cultural factors affecting pain behavior. | |
| Use age-appropriate terminology when asking child about pain experience. | |
| Monitor vital signs. | |
| Evaluate sleep patterns that may be altered by pain. | |
| Monitor side effects of analgesics and narcotics. | |
| Offer approaches to deal with pain such as hypnosis, biofeedback, relaxation techniques, imagery, distraction, cutaneous stimulation, and desensitization. | |
| Leukopenia | Observe for signs and symptoms of infection and inflammation. |
| Monitor vital signs. | |
| Screen visitors for contagious diseases and infections. | |
| Monitor white blood cell count and differential. | |
| Ensure that good hygienic measures are maintained. | |
| Prevent breaks in skin integrity (e.g., keep nails short, prevent injuries). | |
| Thrombocytopenia | Observe for signs and symptoms of bleeding (petechiae and/or hemorrhage). |
| Monitor vital signs. | |
| Monitor platelet count. | |
| Prevent injury or trauma to body. | |
| Avoid taking temperature rectally. | |
| Avoid giving injections. | |
| Monitor platelet transfusions. | |
| Provide pressure on bleeding sites. | |
| Anemia and/or fatigue | Evaluate signs and symptoms of anemia. |
| Monitor complete blood count and differential. | |
| Provide for periods of rest and sleep. | |
| Encourage quiet play activities. | |
| Increased risk of fractures | Avoid weight bearing on affected limb. |
| Prevent accidents and injuries. | |
| Encourage nonambulatory play activities. | |
| Delayed physical and sexual development | Provide anticipatory guidance to parents about child’s growth retardation, skeletal deformities, and delayed sexual development. |
| Discuss possibility of sterility with child and family. | |
| Hypersensitivity to the medication, resulting in anaphylactic shock | Have available the following medications: hydrocortisone, epinephrine, and diphenhydramine (Benadryl). |
| Observe for dyspnea, restlessness, and urticaria. | |
| Phlebitis and necrosis of tissue, resulting from infiltration of IV infusion | Avoid administration of vesicant agents near a joint. |
| Stop IV flow if infiltration is suspected. | |
| Tissue may be treated with drug-specific antidote and hydrocortisone. | |
| Apply warm compress to site (with some chemotherapy, compresses are not applied). | |
| Continue to observe site for signs of inflammation and necrosis. | |
| Grafting and surgical excision may be indicated if necrosis results. |
ECG, Electrocardiogram; IV, intravenous; PO, by mouth.
Discharge Planning and Home Care
The interventions identified for acute care management apply for long-term care as well.
Baquiran DC. Lippincott’s cancer chemotherapy handbook, ed 2. Philadelphia: Lippincott, Williams & Wilkins., 2001.
Barbour V. Long-term safety now priority in leukaemia therapy. Lancet. 2000;355(9211):1247.
Bryant R. Managing side effects of childhood cancer treatment. J Pediatr Nurs. 2003;18(1):87.
Chessells JM. Recent advances in management of acute leukaemia. Arch Dis Child. 2000;82(6):438.
Colby-Graham MF, Chordas C. The childhood leukemias. J Pediatr Nurs. 2003;18(1):87.
Friebert SE, Shurin SB. Acute lymphocytic leukemia. Part 1. ALL: Diagnosis and outlook. Contemp Pediatr. 1998;15(2):118.
Friebert SE, Shurin SB. Acute lymphocytic leukemia. Part 2. ALL: Treatment and beyond. Contemp Pediatr. 1998;15(3):39.
Golub TR, Arceci RJ. Acute myelogenous leukemia. Pizzo PA, Poplack DG. Principles and practice of pediatric oncology, ed 5, Philadelphia: Lippincott, Williams & Wilkins, 2004.
Greaves M. Childhood leukaemia. BMJ. 2002;324(7332):283.
Kanarek RC. Facing the challenge of childhood leukemia. Am J Nurs. 1998;98(7):42.
Kline NE. The pediatric chemotherapy and biotherapy curriculum. Glenview, IL: Association of Pediatric Oncology Nurses, 2004.
Margolin JF, Steuber CP, Poplack DG. Acute lymphoblastic leukemia. Pizzo PA, Poplack DG. Principles and practice of pediatric oncology, ed 5, Philadelphia: Lippincott, Williams & Wilkins, 2004.
Smith MA, Gloeckler Ries LA. Childhood cancer: Incidence, survival and mortality. Pizzo PA, Poplack DG. Principles and practice of pediatric oncology, ed 5, Philadelphia: Lippincott, Williams & Wilkins, 2004.
Yeh CH. Adaptation in children with cancer: research with Roy’s model. Nurs Sci Q. 2001;14(2):141.
