Nursing Diagnoses

The top five things that nurses can focus on when caring for patients with leukemia are:

1. Risk for infection, possibly related to altered white blood cell count, tissue damage, bone marrow suppression, immunosuppression, invasive procedures, and malnutrition.
2. Risk for deficient fluid volume, possibly related to excessive fluid loss from vomiting and diarrhea, decreased fluid intake from nausea and anorexia, and an increased fluid need from a hypermetabolic state. 
3. Acute pain, possibly related to enlarged organs, bone marrow packed with leukemic cells, chemical agents, and psychological factors such as anxiety and fear. 
4. Activity intolerance, possibly related to general weakness, reduced energy stores, hypermetabolic state due to massive production of leukocytes, imbalance between oxygen supply and demand, and effects of drug therapy.
5. Deficient information, possibly related to lack of access to resources, information misinterpretation, or lack of recall.

Maintaining as much autonomy and leisure time as possible is a key factor in maintaining optimism for cancer patients, and anyone, for that matter. Let’s focus on the nursing diagnosis of activity intolerance to see what nurses can do to help a CLL patient continue to participate in activities.

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 (anemia/hypoxia); therapeutic restrictions (isolation/bedrest); effect of drug therapy

Possibly evidenced by verbal report of fatigue or weakness; exertional discomfort or dyspnea; abnormal heart rate or blood pressure response

Desired outcomes include having the patient report a measureable increase in activity tolerance, participating in activities of daily level to level of ability, and able to demonstrate a decrease in physiological signs of intolerance, including pulse, respiration, and blood pressure remain with patient’s normal range

Nursing Interventions

Evaluate reports of fatigue, noting inability to participate in leisure activities or activities of daily living.  Rationale: Effects of leukemia, anemia, and chemotherapy may be cumulative (especially during acute and active treatment phase), necessitating assistance.

Encourage 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 pattern.

Provide quiet environment and uninterrupted rest periods. Encourage rest periods before meals. Rationale: Restores energy needed for activity and cellular regeneration and/or tissue healing.

Implement energy-saving techniques (Sitting, rather than standing, use of shower chair). Assist with ambulation and other activities as indicated. Rationale: Maximizes available energy for self-care tasks.

Schedule meals around chemotherapy. Give oral hygiene before meals and administer anti-emetics as indicated. Rationale: May enhance intake by reducing nausea.

Recommend small, nutritious, high-protein meals and snacks throughout the day. Rationale: Small meals require less energy for digestion than larger meals. Increased intake provides fuel for energy.

Provide supplemental oxygen. Rationale: Maximizes oxygen available for cellular uptake, improving tolerance of activity.

References:
 Five Leukemia Care Plans. 2015. Retrieved April 4, 2015 from http://nurseslabs.com/5-leukemia-nursing-care-plans/

 

Nursing Care

One of the most important things the nurse can do for the patient is establish a meaningful relationship. Most patients with chronic lymphocytic leukemia will live for many years, and they will truly benefit from having a familiar face to talk to about problems and issues that arise. As a nurse, take the time to get to know your patient and their life outside of the hospital. The patient's lifestyle and home situation will also have a great impact on what type of care and treatment the patient will want, so getting to know them will help the nurse be a better advocate for the patient down the road.

Here are a few more suggestions of things the nurse can do. There are many, many ways to care for leukemia patients, so this is just a starting point. This brief summary touches upon all the primary areas of nursing care to focus on, and can be elaborated on.

This nursing care information was obtained from NursesLabs (link below in references) and I found their collection of nursing information to be quite comprehensive. I worked at a cancer facility before entering nursing school, so I am familiar with the patients and their day-to-day struggles. Now that I am closing in on finishing nursing school, I understand how to think like a nurse and can combine those skills with my past experience. I thought NursesLabs covered everything when it comes to caring for cancer patients!

References:

Five Leukemia Nursing Care Plans. 2014. Retrieved April 4, 2015 from http://nurseslabs.com/5-leukemia-nursing-care-plans/

Treatment

Treatment for CLL depends on both the patient and their lifestyle preferences, and the stage of the disease. Your doctor will help you select the treatment that is the best fit for you. Currently, there are five main treatment options, including chemotherapy, monoclonal antibodies, target therapy, supportive therapy, and stem cell transplant.

Chemotherapy is when anti-cancer drugs are given either as pills, or injected directly into the bloodstream. This allows the medicine to reach all parts of the body, and attack cancer cells. This is great for leukemia, as the cancer cells are already moving throughout the bloodstream. The anti-cancer drugs focus on destroying cells that rapidly divide, so they also destroy hair follicles, and cells that line the mouth and intestines. This can often cause nausea and vomiting, making the patient feel very sick. Chemotherapy also attacks the cells in the bone marrow, where the cancer starts, and thereby puts the patient at a higher risk of infection due to lower numbers of white blood cells, and being very tired, due to low numbers of red blood cells.

Monoclonal antibodies are injected into the patient's bloodstream and target a protein on the cancer cells. They are man-made versions of your own immune system cells and work just like your own immune system. While the drug is being injected, you may experience uncomfortable side effects such as itching, nausea, vomiting, rashes and headaches. It is possible to have more serious side effects such as a racing heart, swelling of the tongue, and trouble breathing. A nurse will carefully monitor you for these and the infusion will stop immediately if any of them occur. Other drugs can also be given beforehand to prevent these serious side effects.

Targeted therapy is fairly new, and involves drugs that attack cancer cells by looking for something specific to the cancer cell. This specific thing could be a change in the cell's genes for example. The drug targets that piece of DNA and then kills all cells that look like that. Possible side effects include diarrhea, fatigue, nausea, swelling of the feet and hands, body ache, and rash.

Supportive therapy does not involve treating the cancer itself, but focusing on the side effects. For example, people with CLL are at higher risk of infection since their white blood cell count is affected by the leukemia. We can give them antibodies (disease-fighting agents) from a donor by injection into the bloodstream. This does not help the cancer but can make the patient much more comfortable. For the same reason, it is very important that people living with CLL get all of their vaccines, as they are higher risk of getting sick and staying sick if they catch the flu, or other, more serious viruses like Hepatitis.

All of the above treatments do not actually cure the leukemia - they help to slow the progression and moderate the symptoms. These treatments can do a very good job of this, and give someone many more years to live. However, the stem cell transplant is an attempt at getting rid of all of the places that the cancer can start to grow, and putting in brand new stem cells from another person who does not have cancer. While this treatment can be extremely effective, it is also very complicated. It can take awhile for the leukemia patient's body to adapt to the new stem cells, as they are "foreign" at first. During this transition period, the leukemia patient may be very sick, and see their doctor frequently. There is also the chance that it may not work.

In summary, there are many, many options to treat chronic lymphocytic leukemia! Your doctor will be your best resource, as they are familiar with your case. It is also a good idea to get a second opinion, just to make sure you are getting the treatment that will help you the most. For the most part, doctors will respect your wish to get a second opinion, and be interested to hear what the other doctor thinks, whether they are in agreement or not.


References:

Chemotherapy for chronic lymphocytic leukemia. 2015. Retrieved April 4, 2015 from http://www.cancer.org/cancer/leukemia-chroniclymphocyticcll/detailedguide/leukemia-chronic-lymphocytic-treating-chemotherapy

Monoclonal antibodies for chronic lymphocytic leukemia. 2015. Retrieved April 4, 2015 from http://www.cancer.org/cancer/leukemia-chroniclymphocyticcll/detailedguide/leukemia-chronic-lymphocytic-treating-monoclonal-antibodies

Targeted therapy for chronic lymphocytic leukemia. 2015. Retrieved April 4, 2015 from http://www.cancer.org/cancer/leukemia-chroniclymphocyticcll/detailedguide/leukemia--chronic-lymphocytic-treating-targeted-therapy

Supportive care for chronic lymphocytic leukemia. 2015. Retrieved April 4, 2015 from http://www.cancer.org/cancer/leukemia-chroniclymphocyticcll/detailedguide/leukemia--chronic-lymphocytic-treating-supportive-care

Stem cell transplant for chronic lymphocytic leukemia. 2015. Retrieved April 4, 2015 from http://www.cancer.org/cancer/leukemia-chroniclymphocyticcll/detailedguide/leukemia-chronic-lymphocytic-treating-bone-marrow-stem-cell-transplant

Signs and Symptoms

The most common signs and symptoms of CLL are vague, and can often be attributed to other things, so many people do not know they are sick at the time of diagnosis. The first problems a person will experience are related to altered levels of red blood cells, white blood cells, and platelets. Red blood cells carry oxygen to the cells, so they affect a person's ability to move their body without getting tired. White blood cells fight infections. Platelets help blood clot and stop bleeding. With this knowledge, we can have a better understanding of the signs and symptoms of leukemia.

The most common complaints leukemia patients have are:

• Weakness
• Feeling tired
• Weight loss
• Fever
• Night sweats
• Bruising
• Enlarged lymph nodes (often can be felt as lumps under the skin)
• Feeling full easily (due to enlarged liver or spleen)

 CLL is staged a little differently than other cancers. The staging is based off of how the growing numbers of lymphocytes are affecting the other blood counts, the number of red blood cells and the number of platelets.

• Rai stage 0: Lymphocytosis and no enlargement of the lymph nodes, spleen, or liver, and with near normal red blood cell and platelet counts.
• Rai stage I: Lymphocytosis plus enlarged lymph nodes. The spleen and liver are not enlarged and the red blood cell and platelet counts are near normal.
• Rai stage II: Lymphocytosis plus an enlarged spleen (and possibly an enlarged liver), with or without enlarged lymph nodes. The red blood cell and platelet counts are near normal.
• Rai stage III: Lymphocytosis plus anemia (too few red blood cells), with or without enlarged lymph nodes, spleen, or liver. Platelet counts are near normal.
• Rai stage IV: Lymphocytosis plus thrombocytopenia (too few blood platelets), with or without anemia, enlarged lymph nodes, spleen, or liver.

References:

Signs and symptoms of chronic lymphocytic leukemia. 2015. Retrieved April 4, 2015 from http://www.cancer.org/cancer/leukemia-chroniclymphocyticcll/detailedguide/leukemia--chronic-lymphocytic-signs-symptoms

How is chronic lymphocytic leukemia staged? 2015. Retrieved April 4, 2015 from http://www.cancer.org/cancer/leukemia-chroniclymphocyticcll/detailedguide/leukemia-chronic-lymphocytic-staging

Diagnosis - What Does it Really Mean?

Typically people do not have an idea that they have leukemia before diagnosis. The disease can progress inside the body for years before diagnosis. Usually the first event in a diagnosis happens when the primary care provider (or possibly other specialist) notices an elevated white blood cell count during routine (or specialized) labs, without an explanatory condition. White blood cells can be elevated during infections, so an elevated white blood cell count is not necessarily indicate leukemia.

If leukemia is suspected, the first test the doctor will ask for is a Complete Blood Count (CBC), with differential. The CBC measures and counts red blood cells, platelets, and white blood cells. The differential asks the laboratory to differentiate the different types of white blood cells. This blood draw is usually taken from a vein in the arm. If CLL is present, the CBC will come back with more than 10,000 lymphocytes per cubic millimeter of blood. This condition is called 'lymphocytosis,' meaning too many lymphocytes. However, this result does not always indicate leukemia, and more tests will need to be run. In leukemia, the lymphocytes will also look different than they should, when they are examined under a microscope. When this happens, they are called 'smudge cells.' If the CBC with diff comes back suggesting that CLL is present, the doctor will order another blood test called Flow Cytometry. This test will look at the lymphocytes specifically, and see if they have a certain marker on them that indicates they are CLL. If the cells with these marker are present, and there is more than 5,000 of them per cubic millimeter of blood, a CLL diagnosis can be made.

The blood test is usually enough to diagnose CLL. Most of the time a doctor will order a bone marrow aspiration and biopsy as well at the time of diagnosis. The bone marrow aspiration is a short procedure, where the patient is given a local and/or systemic anesthetic. The doctor inserts a thin, hollow needle into the pelvic bone, and is able to pull about a teaspoon worth of bone marrow out. This bone marrow is then examined, so that the doctors can see if the leukemia cells are mature or immature in their growth, and whether they all cluster together, or spread themselves around in the bone marrow. Both of these pieces of information will help the doctor understand how your disease will progress and what type of treatment will be best for you. If you have CLL, your doctor will likely have you do a bone marrow aspiration and biopsy several times, usually before and after rounds of treatment.

Treatment of CLL will involve other tests as well, possibly including CT and PET scans, so this is not an inclusive list. However, CBC with diff blood draws and bone marrow biopsies are the hallmark tests of leukemia.

References:
How is chronic lymphocytic leukemia diagnosed? 2015. Retrieved April 4, 2015 from http://www.cancer.org/cancer/leukemia-chroniclymphocyticcll/detailedguide/leukemia-chronic-lymphocytic-diagnosis

Pathophysiology

What's happening inside your body that made you get leukemia? How could this be happening when you are feeling just fine?

When CLL first begins to develop in the body, some of the white blood cells called "lymphocytes," have a change in their DNA and begin to look and act differently than they did before. They also don't die when they should - it is normal for cells in the body to die after a little while, as they are making room for fresh, new cells that you create from the food you eat! These changed lymphoctye cells that aren't dying are now called leukemia cells. The leukemia cells continue to develop in the bone marrow until there are so many of them, that they are pushed out into the bloodstream. Here in the bloodstream, they can move around freely and continue to build-up. New leukemia cells continue to grow while the old ones are not dying. The leukemia cells look and act differently than any of the other cells that were in the bloodstream before, so they do not get along well with the other body cells in the blood stream. They can prevent these other, normal cells, from functioning they way they should. When the normal cells cannot function the way they should, you do not feel well. Eventually there will be enough leukemia cells in the bloodstream that they will get pushed out into the organs. If enough leukemia cells make their way into the organ tissue, they can continue to be unfriendly to normal cells, and prevent that organ from functioning as well as it should.

All of your blood cells start out the same, as stem cells. Stem cells are named that because they have the capability to "stem" and grow into any other type of blood cell. The next step for stem cells is to become either lymphoid or myeloid, as you can see in the figure below. Depending on which type of cell is not maturing properly is how doctors determine which type of leukemia you have. This concept here is important to understand, as we will later discuss the bone marrow transplant, a major treatment for leukemia. Since we don't know exactly when, where, or why the problem happens that causes blood cells to mature incorrectly, we put brand new stem cells into a person. We are basically going back to the very beginning of blood cell growth and starting fresh.

SEER Stat Fact Sheets: Leukemia. 2015. Retrieved April 4, 2015 from http://seer.cancer.gov/statfacts/html/leuks.html

References:
What is chronic lymphocytic leukemia? 2015. Retrieved April 4, 2015, from http://www.cancer.org/cancer/leukemia-chroniclymphocyticcll/detailedguide/leukemia-chronic-lymphocytic-what-is-cll

Statistics

Who is most affected by leukemia? Where do you stand among those people? How long do you expect to live? Here we will provide some general statistics about who leukemia is affecting, to give some context to your situation. Hopefully you will find this information helpful, but it is also important not to expect yourself to fit into this statistics. Each person's body is different, and will react to medicine and stress differently. At the same time, there are different treatment options available. Remember that you might do much better than the statistics. It is also possible that you might do much worse. At the end of the day, you don't really know, so take a look at the numbers and then hope for the best. 

Here are some overall statistics for leukemia, including Chronic Lymphocytic Leukemia, Chronic Myeloid Leukemia, Acute Lymphocytic Leukemia, and Acute Myeloid Leukemia:

SEER Stat Fact Sheets: Leukemia. 2015. Retrieved April 4, 2015 from http://seer.cancer.gov/statfacts/html/leuks.html

Both rates of diagnosis and death have remained steady over the last decade. While we may wish for more improvement in both rates, we can still consider it promising that neither rate has increased. The five-year-survival rate is only slightly lower than the 5-year-survival rate for all cancer sites (66%). 

Leukemia is more common in people later in life, although it is also known as a childhood cancer. Here is a look a the distribution of age of diagnosis. Approximately half of the people diagnosed with leukemia will be under the age of 66, and approximately half will be over the age of 66. 

SEER Stat Fact Sheets: Leukemia. 2015. Retrieved April 4, 2015 from http://seer.cancer.gov/statfacts/html/leuks.html

Australia, the USA, Italy, and Ireland have the highest rates of CLL, with white males over age 65 being the most afflicted. It is unknown why these locations and demographics carry the most disease burden. Currently there are no major identifiable risk factors. 

References:
Redaelli, A., Laskin, BL., Stephens, JM., Botteman, MF., and Pashos, CL. (2004). The clinical and epidemiological burden of chronic lymphocytic leukemia. European Journal of Cancer Care, 13(3), 279-87. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/15196232