Adult Medical-Surgical Nursing

1. Adult Medical-Surgical Nursing Haematology Module: Leukaemia (lecture 1) Chemotherapy

2. Leukaemia: Description • A group of malignant disorders affecting: • White blood cells (lymphocytes or granulocytes) • Bone marrow • Lymph system • Spleen

3. Leukaemia: Characteristics • Uncontrolled abnormal white cell division in the bone marrow: • → increased number of dysfunctional white blood cells: • Immature blast cells • Mature but dysfunctional cells • It is a systemic malignant disease: • There is no primary tumour and metastases

4. Leukaemia: Aetiology • Both genetic and environmental factors involved

5. Leukaemia Aetiology: Genetic Propensity • Oncogenes: • Chromosome changes from normal to abnormal genes

6. Leukaemia Aetiology: Environment • Oncogenes are triggered or enhanced by exposure (even prenatal) to: • Chemical agents (benzene, dyes) • Radiation • Environmental pollutants • Smoking • Drugs of addiction • Viruses • (Immunological deficiencies expose further)

7. Leukaemia: Classification • Myeloid Leukaemia: affects granulocytes (from myeloid stem cells) • Lymphocytic Leukaemia: affects lymphocytes (from lymphoid stem cells) • May be: • Acute (blast cells) • Chronic (mature but dysfunctional cells)

8. Leukaemia: Classification • Acute Myelogenous Leukaemia (AML) • Acute Lymphocytic Leukaemia (ALL) • Chronic Myelogenous Leukaemia (CML) • Chronic Lymphocytic Leukaemia (CLL)

9. Acute Myelogenous Leukaemia (AML)

10. AML: Description • 85% of acute leukaemia incidence in adults • Acute onset • Proliferation of myeloblasts, immature granulocytes in the blood circulation

11. AML: Pathophysiology • Uncontrolled abnormal cell division leading to: • Immature dysfunctional myeloblasts crowd the bone marrow and circulation • Infiltrate lymph nodes, spleen, liver, central nervous system • → node enlargement, lymphadenopathy, splenomegaly, hepatomegaly • Crowding out of normal erythroblast and platelet development in bone marrow: ↓ RBC and platelet count

12. AML: Clinical Manifestations • Sudden onset • Patient is very susceptible to infection: • Prone to opportunistic infection as Candida Albicans • Fatigue • Pallor • Bleeding tendency • Bone pain: damaged overcrowded marrow

13. AML: Diagnosis • CBC • Blood film: • Extremely ↑ number of immature white cells (myeloblasts) and ↓ RBC and platelets • Bone marrow biopsy: crowding of myeloblasts • Lumbar puncture • CT scan for evidence of leukaemia outside blood or bone marrow

14. AML: Aims of Treatment • Induce remission (disease control), that is no evidence of the disease : • Blood and bone marrow appear normal (<5% blast cells) • Achieved by chemotherapy • If relapse occurs, must restart the whole treatment regime • Becomes ↑ more difficult to attain remission or cure • May get partial remission (evidence of disease in bone marrow still)

15. Chemotherapy

16. Chemotherapy • The treatment of choice for Leukaemia • Uses different combinations of drugs to destroy malignant cells

17. Chemotherapy: Multiple Drug Protocol • A multiple drug regime or protocol: • Interrupts cell growth and division at different stages of the cell cycle • Therefore it is more effective • Minimises toxicity from high doses of a single agent • Reduces drug resistance

18. Chemotherapy Protocols • Protocols have acronyms: as COAP • Cyclophosphamide • Oncovan • Arabinoside • Prednisone • Each drug taken singly or with another has a specific action on bone marrow cells

19. Stages of Chemotherapy • There are three stages or phases of chemotherapy: • Induction phase • Intensification (consolidation or sanctuary phase) • Maintenance

20. Chemotherapy: Induction Phase • Aggressive treatment: • Uses multiple drug protocol • Seeks to destroy malignant cells in: • Blood • Tissues • Bone marrow • Aims to achieve remission (< 5% blasts in bone marrow)

21. Intensification/ Consolidation Phase • After remission achieved: • Immediate intensive treatment for several months • Aims to eliminate remaining leukaemic cells • Includes intra-thecal chemotherapy (sanctuary phase) if leukaemic cells cross blood-brain barrier (ALL)

22. Chemotherapy: Maintenance • Low doses of chemotherapy continued for years • Follow-up until declared cured

23. Leukaemia: Adjuvant Therapy • Steroids • Sedatives and anti-emetics (Haloperidol, Cyclizine) • Blood transfusions • Neupogen (encourages leukopoiesis) • Bone marrow transplant depends on histocompatibility of donor and recipient • Bone marrow transplant follows remission • Success rate for bone marrow transplant is still quite low

24. Chemotherapy: Toxic Effects • Toxicity to veins and local tissues/ may cause local tissue excoriation • Nephrotoxicity/ cardio- / hepatotoxicity • Nausea and vomiting • Alopecia • Compromised immune response: • Infection risk (isolation) • Reduced erythropoiesis (anaemia) • Reduced platelet production (bleeding tendency)

25. Chemotherapy: Nursing Responsibilities • Preparation: • Gown, double gloves, eye goggles • Designated preparation cupboard • Double-checking • Patient preparation: • Adequate blood count, patient information • Administration: fluid pre-load, pre-medication • IV monitoring, close observation of site • Emotional and physical support throughout and in the community