NURSING PROCESS: THE PATIENT WITH ACUTE LEUKEMIA
Although the clinical picture varies with the type of leukemia in-volved as well as the treatment implemented, the health history may reveal a range of subtle symptoms reported by the patient be-fore the problem is manifested by findings on physical examina-tion. Weakness and fatigue are common manifestations, not only of the leukemia but also of the resulting complications of anemia and infection. If the patient is hospitalized, the assessments should be performed daily, or more frequently as warranted. Because the physical findings may be subtle initially, a thorough, systematic as-sessment incorporating all body systems is essential. For example, a dry cough, mild dyspnea, and diminished breath sounds may in-dicate a pulmonary infection. However, the infection may not be seen initially on the chest x-ray. The lack of neutrophils delays the inflammatory response against the pulmonary infection, and it is the inflammatory response that causes the x-ray changes. The platelet count can become dangerously low, leaving the patient at risk for significant bleeding. The specific body system assessments are delineated in the neutropenic precautions and bleeding pre-cautions, found in Charts 33-9 and 33-10, respectively. When se-rial assessments are performed, current findings are compared with previous findings to evaluate improvement or worsening.
The nurse also must closely monitor the results of laboratory studies. Flow sheets and spreadsheets are particularly useful in tracking the WBC count, ANC, hematocrit, platelet, and creatinine levels, hepatic function tests, and electrolyte levels. Culture results need to be reported immediately so that appropriate antimicrobial therapy can begin or be modified.
Based on the assessment data, major nursing diagnoses for the pa-tient with acute leukemic may include:
• Risk for infection and bleeding
• Risk for impaired skin integrity related to toxic effects of chemotherapy, alteration in nutrition, and impaired mobility
• Impaired gas exchange
• Impaired mucous membranes due to changes in epithelial lining of the gastrointestinal tract from chemotherapy or prolonged use of antimicrobial medications
• Imbalanced nutrition, less than body requirements, related to hypermetabolic state, anorexia, mucositis, pain, and nausea
• Acute pain and discomfort related to mucositis, WBC in-filtration of systemic tissues, fever, and infection
• Hyperthermia related to tumor lysis and infection
• Fatigue and activity intolerance related to anemia and infection
• Impaired physical mobility due to anemia and protective isolation
• Risk for excess fluid volume related to renal dysfunction, hypoproteinemia, need for multiple intravenous medica-tions and blood products
• Diarrhea due to altered gastrointestinal flora, mucosal denudation
• Risk for deficient fluid volume related to potential for diar-rhea, bleeding, infection, and increased metabolic rate
• Self-care deficit due to fatigue, malaise, and protective isolation
• Anxiety due to knowledge deficit and uncertain future
• Disturbed body image related to change in appearance, function, and roles
• Grieving related to anticipatory loss and altered role func-tioning
• Potential for spiritual distress
• Deficient knowledge about disease process, treatment, com-plication management, and self-care measures
Based on the assessment data, potential complications that may develop include:
• Renal dysfunction
• Tumor lysis syndrome
• Nutritional depletion
The major goals for the patient may include absence of com-plications and pain, attainment and maintenance of adequate nutrition, activity tolerance, ability for self-care and to cope with the diagnosis and prognosis, positive body image, and an understanding of the disease process and its treatment.
The nursing interventions related to diminishing the risk for in-fection and for bleeding are delineated in Charts 33-9 and 33-10.
Although emphasis is placed on the oral mucosa, it is important to realize that the entire gastrointestinal mucosa can be altered, not only by the effects of chemotherapy but also from prolonged ad-ministration of antibiotics. Assessment of the oral mucosa must be thorough; therefore, dentures must be removed. Areas to assess in-clude the palate, buccal mucosa, tongue, gums, lips, oropharynx, and the area under the tongue. In addition to identifying and describing lesions, the color and moisture of the mucosa should be noted.
Oral hygiene is very important to diminish the bacteria within the mouth, maintain moisture, and provide comfort. Soft-bristled toothbrushes should be used until the neutrophil and platelet counts become very low; at that time, sponge-tipped applicators should be substituted. Lemon-glycerin swabs and commercial mouthwashes should never be used because the glycerin and alco-hol within them are extremely drying to the tissues. Simple rinses with saline (or saline and baking soda) solutions are inexpensive but effective in cleaning and moistening the oral mucosa. Because the risk of yeast or fungal infection in the mouth is great, other medications are often prescribed, such as chlorhexidine rinses (eg, Peridex) or clotrimazole troches (eg, Mycelex). The nurse re-minds the patient about the importance of these medications to enhance adherence to the therapeutic regimen. Chlorhexidine rinses may discolor the teeth.
To diminish perineal–rectal complications, it is important to cleanse the perineal–rectal area thoroughly after each bowel movement. Women are instructed to cleanse the perineum from front to back. Sitz baths are a comfortable method of cleansing; the perineal–anal region and buttocks must be carefully dried after-ward to minimize the chance of excoriation. Stool softeners should be used to increase the moisture of bowel movements; however, the stool texture must be monitored so that the softeners can be decreased or stopped if the stool becomes too loose.
The disease process can increase, and sepsis further increases, the patient’s metabolic rate and nutritional requirements. Nutri-tional intake is often reduced because of pain and discomfort as-sociated with stomatitis. Mouth care before and after meals and administration of analgesics before eating can help increase in-take. If oral anesthetics are used, the patient must be warned to chew with extreme care to avoid inadvertently biting the tongue or buccal mucosa.
Nausea should not be a major contributing factor, because re-cent advances in antiemetic therapy are highly effective. However, nausea can result from antimicrobial therapy, so some antiemetic therapy may still be required after the chemotherapy has been completed.
Small, frequent feedings of foods that are soft in texture and moderate in temperature may be better tolerated. Low-microbial diets are typically prescribed (avoiding uncooked fruits or vegetables and those without a peelable skin). Nutritional sup-plements are frequently used. Daily body weights (as well as in take and output measurements) are useful in monitoring fluid status.
Calorie counts are useful, as are more formal nutritional assess-ments. Parenteral nutrition is often required to maintain adequate nutrition.
Recurrent fevers are common in acute leukemia; at times, they are accompanied by shaking chills, which can be severe (rigors). Myalgias and arthralgias can result. Acetaminophen is typically given to decrease fever, but it does so by increasing diaphoresis. Sponging with cool water may be useful, but cold water or ice packs should be avoided because the heat cannot dissipate from constricted blood vessels. Bedclothes need frequent changing as well. Gentle back and shoulder massage may provide comfort.
Stomatitis can also cause significant discomfort. In addition to oral hygiene practices, patient-controlled analgesia can be effective in controlling the pain.
Because patients with acute leukemia require hospitalization for extensive nursing care (either during induction or consolida-tion therapy or during resultant complications), sleep deprivation frequently results. Nurses need to implement creative strategies that permit uninterrupted sleep for at least a few hours while still administering necessary medications on time.
With the exception of severe mucositis, less pain is associated with acute leukemia than with many other forms of cancer. How-ever, the amount of psychologic suffering that the patient must en-dure can be immense. Patients greatly benefit from active listening.
Fatigue is a common and oppressive problem. Nursing interven-tions should focus on assisting the patient to establish a balance be-tween activity and rest. Patients with acute leukemia need to maintain some physical activity and exercise to prevent the decon-ditioning that results from inactivity. Use of a high-efficiency par-ticulate air (HEPA) filter mask can permit the patient to ambulate outside the room despite severe neutropenia. Although many pa-tients lack the motivation to use them, stationary bicycles within the room can also be used. At a minimum, patients should be en-couraged to sit up in a chair while awake rather than staying in bed; even this simple activity can improve the patient’s tidal volume and enhance circulation. Physical therapy can also be beneficial.
Febrile episodes, bleeding, and inadequate or overly aggressive fluid replacement can alter the patient’s fluid status. Similarly, persistent diarrhea, vomiting, and long-term use of certain anti-microbial agents can cause significant deficits in electrolytes. In-take and output need to be measured accurately, and daily weights should also be monitored. The patient should be assessed for signs of dehydration as well as fluid overload, with particular at-tention to pulmonary status and the development of dependent edema. Laboratory test results, particularly electrolytes, blood urea nitrogen, creatinine, and hematocrit, should be monitored and compared with previous results. Replacement of electrolytes, par-ticularly potassium and magnesium, is commonly required. Pa-tients receiving amphotericin or certain antibiotics are at increased risk for electrolyte depletion.
Because hygiene measures are so important in this patient popu-lation, they must be performed by the nurse when the patient can-not do so. However, the patient should be encouraged to do as much as possible, to preserve mobility and function as well as self-esteem. Patients may have negative feelings, even disgust that they can no longer care for themselves. Empathetic listening is helpful, as is realistic reassurance that these deficits are temporary. As the patient recovers, it is important to assist him or her to resume more self-care. Patients are usually discharged from the hospital with a central vascular access device (eg, Hickman catheter, PICC), and most patients can care for the catheter with adequate instruction and practice under observation.
Being diagnosed with acute leukemia can be extremely frighten-ing. In many instances, the need to begin treatment is emergent, and patients have little time to process the fact that they have the illness before making decisions about therapy. Providing emo-tional support and discussing the uncertain future are crucial. The nurse also needs to assess how much information patients want to have regarding the illness, its treatment, and potential complications. This desire should be reassessed at intervals, be-cause needs and interest in information change throughout the course of the disease and treatment. Priorities must be identified so that procedures, assessments, and self-care expectations are adequately explained even to those who do not wish extensive information.
Many patients become depressed and begin to grieve for the losses they feel, such as normal family functioning, professional roles and responsibilities, and social roles, as well as physical func-tioning. Nurses can assist patients to identify the source of the grief and encourage them to allow time to adjust to the major life changes produced by the illness. Role restructuring, in both fam-ily and professional life, may be required. Again, when possible, permitting patients to identify options and to take time making significant decisions regarding such restructuring is helpful.
Discharge from the hospital can also provoke anxiety. Although most patients are extremely eager to go home, they may lack con-fidence in their ability to manage potential complications and to resume their normal activity. Close communication between nurses across care settings can reassure patients that they will not be abandoned.
Because acute leukemia is a serious, potentially life-threatening illness, the nurse may offer support to enhance the patient’s spir-itual well-being. The patient’s spiritual and religious practices should be assessed and pastoral services offered. Throughout the patient’s illness, it is important that the nurse assist the patient to maintain hope. However, that hope should be realistic and will certainly change over the course of the illness. For example, the patient may initially hope to be cured, but with repeated relapses and a change to terminal care the same patient may hope for a quiet, dignified death.
Nursing interventions for potential complications were described previously.
Most patients cope better when they have an understanding of what is happening to them. Based on their education, literacy level, and interest, teaching of patient and family should focus on the disease (including some pathophysiology), its treatment, and certainly the significant risk for infection and bleeding (Charts 33-8 and 33-11) that results.
Management of a vascular access device can be taught to most patients or family members. Follow-up and care for the devices may also need to be provided by nurses in an outpatient facility or by a home care agency or a health care providerv.
Shortened hospital stays and outpatient carehave significantly altered care for patients with acute leukemia. In many instances, when the patient is clinically stable but still re-quires parenteral antibiotics or blood products, these procedures can be performed in an outpatient setting. Nurses in these vari-ous settings must communicate regularly. Patients need to learn which parameters are important for them to monitor, and how to monitor them. Specific instructions need to be given as to when the patient should seek care from the physician or a health care provider.
Patients and their families need to have a clear understand-ing of the disease and the prognosis. The nurse acts as an advo-cate to ensure that this information is provided. When patients no longer respond to therapy, it is important to respect their choices about treatment, including measures to prolong life and other end-of-life measures. Advance directives and living wills provide patients with some measure of control during terminal illness.
Many patients in this stage still choose to be cared for at home, and families often need support when considering this option. Coordination of home care services and instruction can help to alleviate anxiety about managing the patient’s care in the home. As the patient becomes weaker, the caregivers must assume more of the patient’s care. In addition, caregivers often need to be en-couraged to take care of themselves, allowing time for rest and ac-cepting emotional support. Hospice staff can assist in providing respite for family members as well as care for the patient. Patients and families also need assistance to cope with changes in their roles and responsibilities. Anticipatory grieving is an essential task during this time.
In patients with acute leukemia, death typically occurs from infection or bleeding. Family members need to have informa-tion about these complications and the measures to take should either occur. Many family members cannot cope with the care required when a patient begins to bleed actively. It is important to delineate alternatives to keeping the patient at home. Should another option be sought, family members who may feel guilty that they could not keep the patient at home will require sup-port from the nurse.
Expected patient outcomes may include:
1) Shows no evidence of infection
2) Experiences no bleeding
3) Has intact oral mucous membranes
a) Participates in oral hygiene regimen
b) Reports no discomfort in mouth
4) Attains optimal level of nutrition
a) Maintains weight with increased food and fluid intake
b) Maintains adequate protein stores (albumin)
5) Reports satisfaction with pain and discomfort levels
6) Has less fatigue and increased activity
7) Maintains fluid and electrolyte balance
8) Participates in self-care
9) Copes with anxiety and grief
a) Discusses concerns and fears
b) Uses stress management strategies appropriately
c) Participates in decisions regarding end-of-life care
10) Absence of complications
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