Sabtu, 14 Mei 2011
Nursing Children with Leukemia
A. Definition
Leukemia is acute or chronic neoplasm of blood-forming cells in bone marrow and spleen (Reeves, 2001). Other characteristic of leukemia is irregular proliferation or accumulation of white blood cells in bone marrow, replacing normal bone marrow elements. Proliferation also occurs in the liver, spleen, and lymph nodes. Non-haematological organ invasion such as the meninges, gastrointestinal tract, kidney, and skin.
Acute lymphocytic leukemia (ALL) often occurs in children. Classified as acute leukemia when there is proliferation of blastocyst (young blood cells) from bone marrow. Acute leukemia is a primary malignancy of bone marrow resulting terdesaknya normal blood components by blood component abnormalities (blastocyst), accompanied by the spread of other organs. Classified as chronic leukemia when found expansion and accumulation of old cells and young cells (Tejawinata, 1996).
Besides acute and chronic, there is also a congenital leukemia is leukemia that are found in infants aged 4 weeks or younger infants.
B. Etiology
The cause of ALL as yet unclear, but most likely due to viruses (oncogenic virus).
Other factors that play a role include:
1. Exogenous factors such as X rays, radioactive rays, and chemicals (benzol, arsenic, sulfate preparations), infection (viruses and bacteria).
2. Endogenous factors such as race
3. Constitutional factors such as chromosomal abnormalities, hereditary (sometimes encountered cases of leukemia in siblings or twins one egg).
Predisposing factors:
1. Genetic factors: a particular virus causes changes in gene structure (T cell leukemia-lymphoma virus / HTLV)
2. Ionizing Radiation: work environment, prenatal care, cancer treatment previously
3. Exposure to chemicals such as benzene, arsenic, chloramphenicol, phenylbutazone, and anti-neoplastic agents.
4. Immunosuppressive medications, drugs such as diethylstilbestrol carcinogenic
5. Hereditary factors such as the one egg twins
6. Chromosomal abnormalities
If the cause of leukemia is caused by a virus, the virus will easily fit into the human body if the virus antigen structure in accordance with the structure of the human antigen. Structure of human antigens formed by the antigen structure of various organs especially the skin and mucous membrane located on the surface of the body (tissue antigen). By WHO, specified in terms of tissue antigens HL-A (human leucocyte locus A). HL-A system of this individual revealed by the law of genetics, so the role of race and family factors as a cause of leukemia can not be ignored.
C. Pathophysiology
Leukemia is a proliferation of blood-making cells that are systemic and often fatal. Leukemia is said blood disease caused by damage to the manufacturers of bone marrow blood cells. The disease is often called blood cancer. Things really work active bone marrow makes blood cells but produced is abnormal blood cells and these cells urgent normal blood cell growth.
There are two mis-conception that must be straightened out about the leukemia, namely:
1. Leukemia is the overproduction of white blood cells, but often found in acute leukemia that low leukocyte counts. This is caused because the resulting production is immatur cells.
2. Tues immatur does not invade and destroy normal blood cells or vascular tissue. Cellular destruction caused by the infiltration and as a consequence of competition to get the element of metabolic food.
D. Leukemia Classification
1. Mielogenus Acute Leukemia (LMA)
LMA on hematopoietic stem cells that later differentiate into all mieloid cells, monocytes, granulocytes (basophils, neutrophil, eosinophil), erythrocytes, and platelets. All age groups can be affected. The incidence increases with age. Leukemia is the most common nonlimfositik.
2. Krinis Mielogenus leukemia (CML)
CML is also included in the system mieloid stem cell malignancy.Namu more abnormal cells than the acute form, so the disease is more mild. CML seldom attack individuals under 20 years old.Manifestations similar to the picture of LMA but with signs and symptoms more mild. The patient showed no symptoms for years, the increase in leukocyte sometimes up to an extraordinary number, enlarged spleen.
3. Chronic lymphocytic leukemia (CLL)
CLL is a mild abnormality of individuals aged 50-70 years. Clinical manifestations of patients are asymptomatic. New diseases diagnosed during a physical examination or treatment of disease.
4. Acute lymphocytic leukemia (ALL)
ALL limfoblast considered a malignant proliferation. Often occurs in children, men more than women. The peak incidence age of 4 years, after age 15 years. ALL is rare. Immatur lymphocytes proliferate in the bone marrow and peripheral tissue that disrupts the normal cell development.
E. Signs and Symptoms
1. Anemia
Caused by the production of red blood cells is less a result of the failure of the bone marrow to produce red blood cells. Characterized by reduced hemoglobin concentration, hematocrit decline, the number of red blood cells lack. Children with leukemia had pale, easily tired, sometimes shortness of breath.
2. High body temperature and simple infection
Due to a decrease in leukocytes, will automatically lower the body resistance due to leukocytes that function to maintain the immune system can not work optimally.
3. Bleeding
The signs of bleeding can be viewed and analyzed from the existence of such mucosal bleeding gums, nose (epistaxis) or bleeding under the skin which is often called petekia. This bleeding can occur spontaneously or from trauma. If very low levels of platelets, bleeding can occur spontaneously.
4. Impairment of consciousness
Due to the infiltration of abnormal cells into the brain can cause a variety of disorders such as seizures to coma.
5. Decrease appetite
6. Weakness and physical exhaustion
F. Clinical Overview
Typical symptoms of pale (may occur suddenly), heat, and bleeding accompanied by splenomegaly and sometimes hepatomegaly and lymphadenopathy. Bleeding can be diagnosed ekimosis, petekia, epistaxis, bleeding gums, etc..
Which are not typical symptoms is joint pain or bone pain which can be misinterpreted as a rheumatic disease. Other symptoms may arise as a result of infiltration of leukemia cells in organs such as purpura on the skin lesions, pleural effusion, cerebral seizures in leukemia.
G. Diagnostic Examination
Examination of peripheral blood, the visible symptom is the presence of pancytopenia, lymphocytosis which sometimes causes the peripheral blood picture and there are monotonous blast cells (patogonomik symptoms for leukemia).
Bone marrow examination found a picture that is only composed of monotonous cells whereas other systems limfopoetik pathological recessive (aplasia secondary).
Node biopsy examination showed proliferation of leukemia cells and cells derived from lymph tissue is pressed as: normal lymphocytes, RES, granulocytes, pulp cells.
70-90% of cases Mielogenus Chronic leukemia (CML) showed chromosomal abnormalities of chromosome 21 (Philadelphia chromosome or Ph 1).
50-70% of patients with acute lymphocytic leukemia (ALL), Acute Leukemia Mielogenus (LMA) has an abnormality in the form:
- Abnormalities of chromosomes as diploid (2n), haploid (2n-a), hiperploid
- Karyotype which pseudodiploid in cases with a diploid chromosome number (2n + a)
- Increase or loss of the chromosome (partial depletion)
- There are a marker chromosome that is the element which is not morphologically normal chromosomes, the form of a very large to very small. To determine the treatment must be known which type of abnormality was found. In leukemia is usually obtained from peripheral blood lymphocytosis of more than 80% or there are blast cells. Also needed examination of the bone marrow by using an electron microscope would be seen the pathological cells.
H. Management
o therapy program
Treatment primarily indicated for 2 things (Netty Tejawinata, 1996) namely:
1. Improving the general condition of the action:
- Solid red blood cell transfusion (Pocket Red Cell-PRC) to overcome anemia. In the event of heavy bleeding and platelet counts less than 10.000/mm ³, it would require platelet transfusions.
- Provision of prophylactic antibiotics to prevent infection.
2. Specific treatment
Especially indicated to cope with the abnormal cells. Implementation depends on the discretion of each hospital, but the basic principles of implementation are as follows:
- Induction to achieve remission: drugs given to treat cancer is often called sitostatica (chemotherapy). Drugs given in combination with a view to reducing the blastocyst cells to 5%, either systemic or intrathecal so as to reduce the symptoms-gajala visible.
- Intensification, which is an intensive treatment for the remaining cells no longer reproduce themselves.
- Prevent the spread of abnormal cells into the central nervous system
- Maintenance therapy (maintenance) is intended to maintain the remission period
3 phases of implementation of Chemotherapy:
1. Induction Phase
Starting 4-6 weeks after the diagnosis is established. In this phase given corticosteroid therapy (prednisone), vineristin, and L-asparaginase. Phase induction declared successful if signs of disease and reduced or absent in the bone marrow found in the number of young cells kuurang than 5%.
2. Phase of the central nervous system prophylaxis
In this phase given methotrexate therapy, cytarabine, and intrathecal hydrocortison through to prevent the invasion of leukemia cells to the brain. Cranial irradiation therapy done only in patients with leukemia who experienced central nervous system disorders.
3. Consolidation
In this phase, the combination therapy was to maintain remisis and reduce the number of leukemia cells circulating in the body.Periodically, do a complete blood count to assess the bone marrow response to treatment. If there is bone marrow suppression, then the treatment is stopped temporarily or reduced drug dosage.
o Treatment of immunologic
Aiming to eliminate the leukemia cells that exist in the body for patients to complete recovery. Entirely discontinued treatment after 3 years of continuous remission.
I. Orphanage Keperawata
Nursing Diagnosis
1. High Risk deficiency bd fluid volume of fluid intake and output, excessive loss: vomiting, bleeding, diarrhea, decreased fluid intake: nausea, anorexia, increased fluid requirements: fever, hipermetabolik.
Objective: The volume of fluid being met
Criteria results:
- Volume of adequate fluid
- Mucosa moist
- Stable vital signs: BP 90/60 mmHg, pulse 100x/menit, RR 20x/menit
- Nadi palpable
- Spending urine 30 ml / hour
- Kapileri refill <2 seconds
Intervention:
a. Monitor fluid intake and output
b. Monitor weight
c. Monitor BP and cardiac frequency
d. Evaluation of skin turgor, capillary filling and mucous membrane condition
e. Give fluid intake 3-4 L / day
f. Inspection of skin / mucous membranes to petekie, ekimosis area; noticed bleeding gums, blood, rust or faint color in the stool and urine, further bleeding from the puncture invasive.
g. Implement measures to prevent tissue injury / bleeding
h. Limit your oral care to wash your mouth when indicated
i. Give a soft food diet
j. Collaboration:
- Give IV fluids as indicated
- Supervise laboratory tests: platelet, hemoglobin / hematocrit, clotting
- Provide HR, platelets, clotting factors
- Maintain an external central vascular access devices (arterial catheter subklavikula, tunneld, implanted port)
- Give medication as indicated: allopurinol, potassium acetate or acetate, sodium bicarbonate, stool softener.
2. Pain b.d physical injury agent
Objective: The pain resolved
Criteria results:
- Patients declared missing or uncontrolled pain
- Shows the behavior of pain management
- There was relaxed and able to break
Intervention:
a. Assess complaints of pain, pay attention to changes in the degree of pain (use a scale of 0-10)
b. Guard your vital signs, notice of non-verbal petujuk eg muscle tension, anxiety
c. Provide quiet environment and reduce the stressful stimuli.
d. Place the client in comfortable position and chock joints, extremities with pillows.
e. Change positions periodically and gentle range of motion exercises help.
f. Provide comfort measures (massage, cold compresses and psychological support)
g. Review / enhance client comfort interventions
h. Evaluate and support the client's coping mechanisms
i. Encourage the use of pain management techniques. Examples: practice relaxation / breathing in, touch.
j. Auxiliary therapeutic activity, relaxation techniques.
k. Collaboration:
- Guard your uric acid levels, give medications as indicated: analgesics (acetaminophen), narcotics (codeine, meperidine, morphine, hidromorfin), antianxiety agents (diazepam, lorazepam)
3. Bd high risk of infection secondary decrease the body's defense system (impaired maturation of SDP, the increase in the number of lymphocytes immatur, immunosuppression, bone marrow suppression)
Objective: The client is free from infection
Criteria results:
- Situation normal temperature
- Negative culture results
- Increased healing
Intervention:
a. Place in a special room. Limit visitors as indicated
b. Wash hands for all staff and visitors
c. Monitor the temperature, consider the relationship between rising temperatures and chemotherapy treatment. Observations fever in connection with tachycardia, hypotension, changes probably faint.
d. Prevent shivering: increase fluids, give compress
e. Encourage frequent change position, breathe deeply, and cough
f. Auscultation of breath sounds, gurgling note, ronchi; inspection secretion to changes in characteristics, increased sputum or sputum sample thick.
g. Inspection of the skin to tender, the area erythematosus; open wound. Clean the skin with antibacterial solution.
h. Inspection of the mouth mucous membrane. Clean mouth with soft toothbrush.
i. Improve cleanliness of perianal
j. Diets high in protein and fluid
k. Avoid invasive procedures (needle puncture and injection) when possible
l. Collaboration
- Supervise lab examination. For example: complete blood count, whether the SDP fall or sudden changes in neutrophil; culture grams / sensitivity.
Review of chest photo series, give the medicine according to indications, avoid antipyretics that contain aspirin, given a diet low in bacteria, eg cooked food.
4. The risk of bleeding b.d thrombocytopenia
Objective: The client is free from symptoms of bleeding
Criteria results:
- TD 90/60 mmHg
- Nadi 100x/menit
- Excretion and secretion of a negative effect on blood
- Ht 40-54% (men), 37-47% (female)
- Hb 14-18 g%
Intervention:
a. Monitor platelet count with the number 50.000/ml, the risk of bleeding. Monitor Hct and Hb of the signs of bleeding.
b. Ask the client to remind the nurse when there is seepage of blood from the gums
c. Inspection kkulit, mouth, nose, urine, faeces, vomit, and IV puncture site of bleeding.
d. Use a small needle
e. If there is bleeding, elevate the affected part and give a cold compress and gently push
f. Give bearing beds to prevent trauma
g. Instruct the client to use a soft toothbrush or an electric shaver.
5. General weakness of activity intolerance b.d
Objective: The client is able to tolerate activity
Criteria results:
- Increased tolerance activity can be measured
- Participating in daily activities according to ability level
- Showing signs of physiological decline intolerant eg pulse, respiration, and TD within normal limits
Intervention:
a. Evaluation report weakness, consider the inability to participate in activities. Give a calm environment and rest periods without interruption.
b. Implement energy saving techniques. Example: better sitting than standing.
c. Schedule meals around chemotherapy. Keep your mouth clean. Give antiemetics as indicated.
d. Collaboration: provide additional oxygen.
J. Bibliography
Behrman, Kliegman, Arvin. 2000. Pediatrics. EGC
Ngastiyah. 1997. Child Care Hospital. EGC
Nursalam, et al. 2005. Nursing Infants and Children. Salemba Merdeka
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