Nursing Leukemia In Children

Nursing Leukemia In Children Leukemia, Childhood Pathophysiology Lymphoid leukemia, or acute lymphocytic (acute lymphoid, lymphocytic, leukemia, ALL) is a network of cancer that produces white blood cells (leukocytes).  

Immature leukocytes produced in excessive amounts or abnormal, and leukocyte-leukocyte was invaded various organs. Leukemik cells infiltrate into the bone marrow, replace the elements of a normal cell. Consequently, anemia, and red blood cells produced in insufficient quantities. Bleeding arise due to the declining number of circulating platelets. Infection also occurred more frequently due to the reduced number of normal leukocytes. Invasion leukemik cells into vital organs causing hepatomegaly, splenomegaly, and lymphadenopathy.

Acute non lymphoid leukemia (acute nonlymphoid leukemia, ANLL) includes several types of leukemia herikut: mieloblastik acute leukemia, acute monoblastik leukemia, and acute leukemia mielositik. Arise bone marrow dysfunction, which causes a decreased number of red blood cells, neutrons, and platelets. Leukemik cells infiltrate the lymph nodes, spleen, liver, bone, and central nervous system (CNS), as well as the reproductive organs. Kloroma or Kaposi granulositik found in a number of children affected.

Incidence
ALL

1. Leukemia is a type of childhood cancer is most common; ALL occurred in 80% of cases of child leukemia.
2. The highest incidence occurs in children aged between 3 and 5 years.
3. Children peretnpuan showed a better prognosis than boys. At least 60% to 70% will achieve cure or long-term survival.
4. African American Children have fewer frequency of remission and median survival rates are also lower.
 

ANLL
1. There is no age incidence peaks.
2. ANLL includes 15% to 25% of cases of leukemia in children.
3. Increased risk of developing this disease in children who have congenital chromosomal abnormalities such as Down syndrome.
4. It's harder than ALL in terms of inducing remission (remission rate 70%). About 50% will survive.
5. Brakes contents shorter than children with ALL.
6. 50% of children who have bone marrow transplant has prolonged remission.


Clinical manifestations ALL 1. Evidence of anemia, bleeding, and / or infection a. Fever b. Fatigue c. Pale d. Anorexia e. Petekie and / or bleeding f. Joint pain and bone g. Abdominal pain is not clear h. Weight loss i. Enlargement and fibrosis reticuloendothelial system organs-liver, spleen, and lymph nodes 


2. Increased intracranial pressure due to infiltration of the meninges a. Pain and stiff neck b. Headache c. Irritability d. Lethargy e. Throw up f. Papil edema g. Coma
3. The symptoms of central nervous system associated with the affected parts of the system a. The weakness of the lower limb b. Difficulty urinating c. Difficulty learning, especially math and hapalan (advanced side effects of therapy) 


ANLL
1. Gum hypertrophy
2. Kloroma spinal (mass lesions)
3. Necrotic lesions or ulserosa perirektal
4. Hepatomegaly and splenomegaly (in less than 50% of children)
5. Clinical manifestations similar to patients with ALL (see section ALL)

COMPLICATIONS
ALL

1. Failure of bone marrow
2. Infection
3. Hepatomegaly
4. Splenomegaly
5. Lymphadenopathy

ANLL

1. Failure of bone marrow
2. Infection
3. Disseminated intravascular coagulation (DIC)
4. Splenomegaly
5. Hepatomegaly


LABORATORY AND DIAGNOSTIC TESTS
1. A complete blood count, white blood cells of children with less than 10.000/mm3 prognosis when diagnosed as having the most balk; hitting the white blood cells more than 50.000/mm3 is less Balk prognostic sign in children of all ages. Levels of hemoglobin and low hematocrit indicates anemia. Low platelet count indicates a potential bleeding
2. -lumbar puncture to assess CNS involvement
3. Photo-detecting thoracic mediastinal involvement
4. Bone-marrow aspiration found 25% confirms the diagnosis of blast cells
5. Bone scan or survey framework examine the involvement of the bone-
6. Scanning kidney, liver, and spleen-examine infiltrates leukemik
7. flitting platelet-show freezing capacity


MEDICAL MANAGEMENT
Treatment protocols vary according to type of leukemia and type of drugs given to children. The process of induction of remission in children consists of three phases: induction, consolidation and maintenance. During the induction phase (approximately 3 to 6 weeks) the child, receive a variety of chemotherapeutic agents for induction of remission. Intensive therapy was extended from 2 to 3 weeks during the consolidation phase to prevent the involvement of the central nervous system and other vital organs. Therapy to prevent CNS disease is important. Maintenance therapy is given for several years after diagnosis to prolong remission. Some drugs used for children's leukemia is prednisone, vincristine, asparaginase, methotrexate, merkaptopurin, cytarabine, allopurinol, cyclophosphamide, and daunorubicin.


Prednisone
Terutaina prednisone used because antiinflamasinya strong effect on disease involving multiple organ systems. Prednisone used to treat acute childhood leukemia. Possible side effects are:
1. Disorders of fluid and electrolytes-sodium retention, fluid retention, congestive heart failure in susceptible patients, potassium kchilangan, hypertension.
2. Musculoskeletal effects, muscle weakness, osteoporosis, pathological fractures in long bones.
3. Effects Gastrointestinal-peptic ulcer with possible bleeding, pancreatitis, abdominal distension, increased appetite, weight increase.
4. Dermatological effects-impaired wound healing, and ekimosis petekie, facial erythema, hirsutism, hypopigmentation / hyperpigmentation.
5. Neurological effects, increased intracranial pressure with papil edema, convulsions, vertigo, and headaches, irritability, feelings are changing.
6. Effects of endocrine-development of cushingoid state, further manifestation of diabetes mellitus.
7. Stock-cataract ophthalmic subkapsular posterior.
8. Metabolic effects, negative nitrogen balance due to protein catabolism
The dose is calculated individually based on the severity of the disease and the response of the child, not based on strict ratios according to age or weight. Prednisone is given orally (PO).
 

Vincristine (Oncovin)
Vincristine are antineoplastic agents which menghainbat cell division during metaphase. These drugs are used together with cyclophosphamide (Cytoxan) to treat ALL. Possible side effects are:
1. -neuromuscular effects of peripheral neuropathy, nerve pain, paresthesias in arms and legs, loss of deep tendon racks, jaw pain, Fool drop.
2. Haematological effects, thrombocytopenia, anemia, leukopenia.
3. Gastrointestinal effects, stomatitis, anorexia, nausea, vomiting, diarrhea, constipation, paralytic ileus.
4. Other-convulsions, hyperkalemia, hiperurisemia
Vincristine administered IV. Avoid extravasation.

Asparaginase
Asparaginase lower levels of asparagine (an amino acid needed for tumor growth). Asparaginase used to treat ALL. Possible side effects of this drug are:
1. Manifestation of allergic-asparaginase is a side effect of the most severe that can be reduced by the addition merkaptopurin, cytosine arabinosid, and other immunosuppressants.
a. Fever and chills within 1 minute after administration
b. Skin reactions
c. Respiratory distress
d. Hypotension
e. Pain Substernal
f. Nausea and vomiting
g. Anaphylaxis


2. Liver toxicity with jaundice, hypoalbuminemia, and sometimes depressed clotting factor.
3. Pancreatitis
4. Diabetes mellitus
5. Calcium metabolism disorders
Asparaginase dose varies depending on the individual. The drug is given by IM.

Methotrexate (Amethopterin)
Methotrexate is classified as an antimetabolite. These drugs inhibit the metabolism of folic acid are essential for nucleoprotein synthesis required by cells that divide rapidly. Methotrexate is used to treat ALL.


If there is infection, methotrexate should be used with extreme caution. Therapy with other bone marrow depressants should also be avoided except when patients are in need of its use. These drugs can be administered orally (PO), intramuscular (IM), intravenous (IV), or intrathecal. Avoid vitamin containing folic acid if the child was given methotrexate. Possible side effects of methotrexate are as follows.
1. Skin-rash reaction general erythema, urticaria, acne, pruritus
2. Sometimes alopecia
3. Ulceration of the mouth and gastrointestinal tract (GI)
4. Shiver
5. Fever
6. Throw up
7. Diarrhea
8. Cystitis
9. Bone marrow depression (sometimes accompanied by bleeding or septicemia)
10. Liver toxicity
11. Pneumonitis


Merkaptopurin (Purinetol)
Merkaptopurin function blocking nucleic acid synthesis, which is especially necessary when the cells grow and reproduce itself rapidly.
The primary effect of merkaptopurin occur in the network where there is a rapid cell growth and metabolism of nucleic frequency is also high (eg, bone marrow and stomach epithelium). A decline in the production of leukocytes, platelets, and reticulocyte. These drugs are used in the treatment of ALL. Possible side effects are as follows:
1. Anorexia
2. Nausea and vomiting
3. Diarrhea (sometimes accompanied by blood) because of injury to the GI epithelium.
4. Degenerative changes are accompanied by jaundice due to liver merkaptopurin giving high doses.
5. Bone marrow depression


Merkaptopurin only given orally (PO).
Cytarabine is currently used to induce remission in patients with acute leukemia granulositik. Cytarabine is a bone marrow suppressant strong. Patients receiving this drug should be watched closely and, during induction therapy, should be examined leukocyte count and platelet count are common.
Modified or delayed treatment when these drug-induced depression tclah menycbabkan platelet count less than 50.000/mm3 or hitting less than 1.000/mm3 polymorphonuclear granulocytes. Possible side effects are as follows.
1. Nausea and vomiting
2. Leukopenia, thrombocytopenia, bone marrow suppression
3. Anemia
4. Rash
5. Anorexia
6. Bleeding (all tempt)
7. Diarrhea
8. Inflammation or ulceration of the mouth
9. Megaloblastosis
10. Liver dysfunction
11. Anafi laksis
12. Headache
Cytarabine is not active when given orally. Cytarabine can be administered by IV infusion or injection. Cytarabine should be stored in the refrigerator until used.

Allopurinol (Zyloprim)
Allopurinol inhibits uric acid production by inhibiting scgera biochemical reactions that precede the formation of uric acid. The result is a decrease in uric acid levels in blood and urine. Allopurinol given as prophylaxis to prevent the deposit of uric tissue or kidney stones in patients with leukemia who are undergoing chemotherapy causes increased serum uric acid. Allopurinol also inhibits the oxidation merkaptopurin merkaptopurin must therefore use in smaller doses (one-quarter to one third of usual dose). Possible side effects of allopurinol are:
1. Sometimes liver toxicity
2. Pen ingkatan serum glutamic-oxaloacelic Iransaminase (SGOT) and serum glutamic-pyruvic transaminase (SGPT) are asymptomatic.
Allopurinol given orally. Increase hydration until at least two times the amount of maintenance. See treatment protocol dose determination.


Cyclophosphamide (Cytoxan)
Cyclophosphamide is a powerful antitumor agents of the nitrogen mustard group and chelating agents. Mechanism of action of cyclophosphamide is certainly not yet known. Unlike the other mustard compounds, cyclophosphamide is not active when direct contact with bacteria, leukocytes, and most tumor cells in culture. Cyclophosphamide is used in the treatment of ALL and acute leukemia monositik. Possible side effects of the drug in i is:
1. Nausea and vomiting

2. Anorexia

3. Alopecia (occurring in at least 50% of patients)

4. Leukopenia (decreased white blood cell count)
a. Expected Effect
b. Usually a guideline therapy
c. Cause the child susceptible to bacterial infections

5. Hemorrhage sterile cystitis (bladder mucosa may be injured because of certain active mustard derivatives excreted in urine)

6. Liver dysfunction

7. Kardiotoksisitas
Siklofosfam id given through IV drip infusion quick, oral, or IM.


Daunorubicin (Daunomycin)
Daunorubicin bound to DNA. Daunorubicin is used to inhibit cell division during the treatment of acute leukemia. Possible side effects of this drug are as follows:
1. Venous sclerosis (use two needle technique: mixed drugs with a needle and dispose of the needle; did the injection with a new needle)
2. Nausea and vomiting (immediately after injection)
3. Bone marrow depression
4. Cardiac dysrhythmia and death (rare; occur at total doses greater than 650 mg/m2)
5. Increased liver enzymes (ALT, AST)
6. Change the color to red urine
Daunorubicin given by IV injection. See treatment protocol.


NURSING ASSESSMENT
1. See the Assessment of Cardiovascular, Respiratory, and Neurological in Appendix A.
2. Assess the child's reaction to chemotherapy.
3. Review the signs and symptoms of infection.
4. Review the signs and symptoms of hemorrhage.
5. Review the signs and symptoms of complications: somnolen radiation, symptoms of CNS, cell lysis.
6. Assess child and family coping.

NURSING DIAGNOSIS
- activity intolerance
- Risk of infection
- Excess fluid volume
- Damage to tissue integrity
- The imbalance nutrition: less than body requirements
- Risk of injury
- Impaired body image
- Anxiety
- Decrease in cardiac output
- Risk ineffective respiration function
- Fatigue
- Delays in growth and development
- Changes in family process
- management ineffectiveness of treatment programs


NURSING INTERVENTION
1. Monitor the child to know the reaction to treatment.

2. Keep track of the signs and symptoms of infection.
a. Beware that the fever is the most important sign of infection.
b. Treat all children as if they all suffer neutropenik to obtain test results. Their isolation from other clinic patients, especially children with infectious diseases, particularly varicella.
c. Ask the child to wear a mask when with others and suffered heavy neutropenik (leukocytes less than 1.000/mm3).
d. Beware that if a child is suffering neutropenik, is not allowed to undergo chemotherapy. Children can receive IV antibiotics if fever also occur. (Over many patients with leukemia who died of infection rather than because of illness.)

3. Keep track of the signs and symptoms of hemorrhage.
a. Check the bruises and petekie on the skin.
b: Check the nosebleeds and bleeding gums.
c. If given the injection, press bckas prick longer than normal (approximately 3 to 5 minutes) to ensure bleeding has stopped. Check again to make sure it does not happen again bleeding.


4. Keep track of the signs and symptoms of complications.
a. Somnolen radiation: Starting 6 weeks after receiving radiation kraniospinal, the child showed severe fatigue and anorexia for approximately 1 to 3 weeks. Parents often feel worried about the occurrence of relapse at this time and need to be convinced.
b. CNS symptoms: Headache, blurred or double vision, vomiting, these symptoms may indicate CNS involvement in this leukemia.
c. Respiratory symptoms: cough, congestion pare, dyspnea, the symptoms indicating the existence of pneumonia or other respiratory infection.
d. Cell lysis: a rapid cell lysis after chemotherapy can affect blood chemistry, resulting in increased calcium and potassium.

5. Monitor the concern and anxiety about the diagnosis of cancer and its relationship to treatment; monitor emotional responses, such as anger, denial, and sadness.

6. Keep track of the disturbance in the functioning of the family.
a. Dasari all interventions with the cultural background, religion, education, and socio-economic families.
b. Involve siblings in the care of many children as possible because they are very concerned about the changes that occur in children who are sick and family functions.
c. Consider the possibility that siblings feel guilt and blame.

d. Increase the family unit by providing freedom of visiting hours for 24 hours for all members of the family.
Planning Home and Home Care Interventions listed in the management of acute care are also applicable to long-term care.

EXPECTED RESULTS
1. Children will achieve remission.
2. Children will be free of disease complications (such as infection, anemia, and manifestations of CNS) and complications of long-term therapy.
3. Children and families will learn to perform effective coping to deal with life and management of the disease.

             
Source: fkunhas