# data[].attributes.body
Regularly monitor patients’ symptoms & vital signs

Monitor patient for potential complications of:

Anemia

Infection

Bleeding

Weakness & fatigue

Educate the patient about the disease, treatment, and what to expect

Teach the patient & family how to identify infection or abnormal bleeding

# data[].attributes.body
Health history

Physical examination

Lab tests

Leukocyte count

CBC

ANC

Hematocrit

Hemoglobin

Platelets

Bleeding times

aPTT

PT

INR

Uric acid levels

Electrolytes

Culture reports

# data[].attributes.body
- Closely monitor platelet count
- Assess the skin for petechiae or bruises
- Prepare for emergency blood transfusion

# data[].attributes.body
- Nutrition & diet are extremely vital, especially iron-rich foods
- Iron supplements

# data[].attributes.body
- CBC
- Iron studies
- Stool test
- Bone marrow aspiration (definitive diagnosis)

# data[].attributes.body
- Administer IV fluids as ordered
- Prevent hypotension / BP from getting any lower

# data[].attributes.headline
Monitor for changes in level of consciousness ~

# data[].attributes.subject
Monitor for changes in level of consciousness ~

# data[].attributes.body
- Monitor closely for change in LOC
- May be a relapse
- Notify physician ASAP

# data[].attributes.body
- Discuss with physician
- Specific medications may need to be discontinued or change dose

# data[].attributes.body
- Bed should be in the lowest position with side rails up x3
- Asks for assistance before getting out of bed
- Place necessary items within reach (call button, light, etc.)
- Tell the patient to change positions slowly

# data[].attributes.body
- Health history & physical exam
- Medication history
- Herbal or alternative therapies
- Alcohol or smoking history
- Family history
- History of blood transfusion
- Nutritional assessment
- Determine cause of syncope with physician

# data[].attributes.headline
What nursing interventions should be put into place for the patient?

# data[].attributes.subject
What nursing interventions should be put into place for the patient?

# data[].attributes.headline
What are the appropriate assessments the nurse needs to conduct?

# data[].attributes.subject
What are the appropriate assessments the nurse needs to conduct?

# data[].attributes.body
Elevated white blood cells

Decreased hemoglobin

Decreased hematocrit

Decreased platelets

Increased bleeding times

Elevated uric acid levels

# data[].attributes.headline
5 - (a) What are the key assessment and nursing interventions that need to be completed for a patient with leukemia?

# data[].attributes.subject
5 - (a) What are the key assessment and nursing interventions that need to be completed for a patient with leukemia?

# data[].attributes.headline
(2) Nursing assessments & interventions for DIC

# data[].attributes.subject
(2) Nursing assessments & interventions for DIC

# data[].attributes.body
Nursing Assessments:
Assessing for bleeding
Rational: DIC is an abnormality in the clotting cascade that causes both thrombi and bleeding. The mortality levels could be really high, so it is important to note and report bleeding
-integumentary: visible petechiae, bleeding gums, oozing from wounds, previous injection sites and near catheters, epistaxis diffuse ecchymoses, subcutaneous hemorrhage, joint pain (could be a sign of bleeding in the joints)
-circulatory/respiratory: tachycardia, tachypnea, high pitched bronchial breath sounds,, increased consolidation, S&S of ARDS
-gastrointestinal: hematemesis, melena, peritoneal bleeding (board like abdomen)
-renal: hematuria
-neurologic: anxiety, restlessness, altered LOC, headache, visual disturbances, conjunctival hemorrhage

Assess for thrombus:
Rational: DIC is an abnormality in the clotting cascade that causes both thrombi and bleeding. The mortality levels could be really high, so it is important to note and report possible thrombi
-integumentary: decrease in temperature (sign of decreased blood flow) increased pain, cyanosis of the extremities, nose or earlobes (signs of occlusion), focal ischemia (lack of blood flow), superficial gangrene (lack of O2)
-circulatory/respiratory: decreased pulses, increased capillary refill time, hypoxia (could be a sign of clot in the lung), dyspnea, chest pain with deep inspiration, decreased breath sounds over areas of lung (sign of large embolism)
-gastrointestinal: heartburn
-renal: decreased urine output
-neurologic: decreased A&O, decreased pupillary reaction, decreased strength, decreased response

Assess labs:
-decreased platelets
-increased PT and aPTT
-decreased fibrinogen
-increased d dimer

Nursing interventions:
The most important intervention is to treat the underlying cause
-patient moved to ICU: needs critical care and closer monitoring
-avoid any activity or procedure that increased intracranial pressure: preventing intracranial bleeding
-monitor VS, abdominal girth, urine output: could show early signs of bleeding/shock
-avoid medications that increase bleeding risk (ASA, NSAIDS)
-avoid rectal temp, suppositories, IM injections: decrease bleeding
-monitor external bleeding-number of dressings, suction output, etc.
-low pressure suctioning only, careful and gentle oral care: preventing bleeding
-auscultate breath sounds q 2-4 hours: listening for crackles or absent sounds which could indicate thrombi
-administer diuretics as prescribed and monitor intake fluid volume: decrease fluid volume

# data[].attributes.body
Pathophysiology:

ALL progresses quickly, resulting from the uncontrolled proliferation of lymphocyte precursor cells, or lymphoblasts (stem cells - immature cells).
- Accumulation: Due to the precipitating factors, immature, non-functioning white blood cells appear to accumulate first in the tissue where they originate (e.g., lymphocytes in lymph tissue; granulocytes in bone marrow).
- Infiltration: These immature WBCs then spill into the bloodstream, traveling, and infiltrating other tissues.
- Malfunction: Eventually, this infiltration of immature WBCs results in organ malfunction as a result of their intrusion and hemorrhage.

Incidences:

- ALL is more common in males than females
- ALL is more common Caucasians, especially in people of Jewish descent.
- ALL is seen most often in children between the ages of 2 and 5, especially those who live in urban and industrialized areas (the most common form of cancer in children).
- While 80% of leukemias diagnosed in children aged 2 to 5 are ALL, ALL accounts for only about 20% of adult leukemia diagnoses.

Progression/Survival Rate:

ALL is very responsive to treatment.
- While the 5-year survival rate is >85% in children, the 3-year survival rate is <45% for adults.

Causes/Risk Factors:

- Congenital Disorders: Down syndrome, Bloom syndrome, Fanconi anemia, congenital agammaglobulinemia, and ataxia-telangiectasia usually predisposes ALL.
- Family Tendency: Genetics play a part in the development of ALL.
- Viruses: Since viral remnants have been found in leukemic cells, they may likely be a cause of ALL.

Clinical Manifestations:

Signs of acute lymphocytic leukemia may be gradual or sudden.
- High Fever: Elevated temperature accompanies by thrombocytopenia and abnormal bleeding, such as nosebleeds and gingival bleeding.
- Bruising: Easy bruising following minor trauma.
- Dyspnea: A decrease in mature blood cells leads to dyspnea.
- Anemia: Anemia is present in ALL due to the decrease in mature red blood cells.
- Fatigue: Patient will experience excess fatigue.
- Tachycardia: As the immature blood cells multiply and have difficulty carrying oxygen, the body compensates by pumping blood faster than usual.
- Pain: Pain from an enlarged liver or spleen, as well as bone pain is common.
The CNS is frequently a site for leukemic cells; thus, patients may exhibit cranial nerve palsies or headache and vomiting because of meningeal involvement.

Complications:

If left untreated, acute lymphocytic leukemia is fatal; usually due to complications resulting from leukemic cell infiltration of the bone marrow and other vital organs.
- Infection: Immature WBCs are unable to defend the body against invading pathogens, leaving the patient immunocompromised and at great risk for infection.
- Organ Malfunction: Infiltration of immature WBCs into the bloodstream and tissues, results in organ malfunction as a result of their intrusion and hemorrhage.

Assessment and Diagnostic Findings:

Diagnosis of ALL can be confirmed with a combination of the following:
- Bone Marrow Aspiration: Typical clinical findings and bone marrow aspirate showing a proliferation of immature WBCs confirm ALL.
- Bone Marrow Biopsy: A bone marrow biopsy, usually of the posterior superior iliac spine, is part of the diagnostic workup.
- Blood Counts: Blood counts show severe anemia, thrombocytopenia, and neutropenia.
- Differential Leukocyte Count: Differential leukocyte count determines cell type.
- Lumbar Puncture: Lumbar puncture detects meningeal involvement.
- Uric Acid Levels: Elevated uric acid levels and lactic dehydrogenase levels are commonly found.

Medical Management:

The goal of treatment is to obtain remission without excess toxicity and with a rapid hematologic recovery so that additional therapy can be given if needed.
- Systemic Chemotherapy: Systemic chemotherapy aims to eradicate leukemic cells and induce remission (<5% of blast cells in the marrow and peripheral blood are normal).
- Platelet Transfusion: Platelet transfusion is performed to prevent bleeding.
- Red Blood Cell Transfusion: RBC transfusion is performed to prevent anemia.

Pharmacologic Therapy:

The following are drugs included in chemotherapy used to treat ALL:
- Vincristine: Vincristine is an anti-cancer (antineoplastic or cytotoxic) chemotherapy drug and is classified as a plant alkaloid.
- Prednisone: This drug works by altering the body's normal immune system responses.
- Cytarabine: Cytarabine belongs to the category of chemotherapy called antimetabolites, wherein when the cells incorporate these substances into the cellular metabolism, they are unable to divide and they attack cells at very specific phases in the cycle.
- L-asparaginase: Asparaginase breaks down asparagine in the body, so since the cancer cells cannot make more asparagine, they die.
- Daunorubicin: Daunorubicin is classified as an antitumor antibiotic that is made from natural products produced by species of the soil fungus Streptomyces, and these drugs act during multiple phases of the cell cycle and are considered cell-cycle specific.
- Antibiotics; Antifungals; Antivirals: These control infection, a common complication of acute leukemias.

Surgical Management:

Aggressive treatment of ALL may include surgical intervention.
- Bone Marrow Transplant
- Stem Cell Transplant: One of the latest developments in the treatment of leukemias.

Nursing Management:

The care plan for the leukemic patient should emphasize comfort, minimize the adverse effects of chemotherapy, promote preservation of veins, manage complications, and provide teaching and psychological support.
Goals:
- Absence of pain.
- Attainment and maintenance of adequate nutrition.
- Activity tolerance.
- Ability to provide self-care and to cope with diagnosis and prognosis.
- Positive body image.

# data[].attributes.body
Pathophysiology:

In contrast to ALL which develop in immature lymphocytes, most leukemia cells in CLL are fully mature, typically deriving from a malignant clone of B lymphocytes.
- Accumulation: One mechanism that results in this oncogenesis is that these cells do not go through the process of apoptosis (programmed cell death), leading ti an excessive amount of these cells accumulating in the marrow and circulation.
- Infiltration: Because these lymphocytes are small, they easily travel through the blood capillaries, often infiltrating and accumulating within the lymph nodes and spleen.

Incidence:

- CLL is a common malignancy of older adults, with an average age 72 years at diagnosis.
- CLL is the most prevalent time of adult leukemia in the Western world.

Progression/Survival Rate:

While many patients will have a normal life expectancy, others will have a very short life expectancy due to the aggressive nature of the disease.
- Prolymphocytic leukemia transformation: Around 10% of patients will experience a gradual transformation of their disease to one that becomes resistant to chemotherapy.
- Richter's transformation: Slightly fewer patients will experience Richter's transformation, which is a sudden transformation to a very aggressive lymphoma; this transformation results in markedly increased lymphadenopathy, splenomegaly, worsening B symptoms, and survival of only a few months despite treatment.

Causes/Risk Factors:

- Family Tendency: A strong familial predisposition exists with CLL; the disease can occur in 10% of those with a first- or second-degree relative with the same diagnosis.
- Toxin Exposure: Veterans of the Vietnam War who were exposed to Agent Orange may be at risk for developing CLL.

Clinical Manifestations:

Many symptoms are asymptomatic and diagnosed incidentally during routine physical examinations or during treatment for another disease.
- Lymphocytosis: An increased lymphocyte count (lymphocytosis) is always present.
- The erythrocyte and platelet count may be normal or, in later stages of the illness, decreased.
- Lymphadenopathy: Enlargement of the lymph nodes is common; can be severe and painful.
- Splenomegaly: Spleen may also be enlarged.
- B Symptoms: A constellation of symptoms including fevers, drenching sweats (especially at night), and unintentional weight loss.
- Impaired T-Cell Function: May result in tumor progression and increased susceptibility to second malignancies and infections.

Complications:

- Autoimmune complications can occur at any stage, as either autoimmune hemolytic anemia or idiopathic thrombocytopenia purpura. In the autoimmune process, the reticuloendothelial system destroys the body's own erythrocytes of platelets.
- Infection: Life-threatening infections are particularly common with advanced disease, and account for 50% to 60% of all deaths in patients with CLL
- Patients with CLL have a greater risk for developing other cancers (risk is 2.2 times higher than the expected incidence per the SEER database); second cancers typically involve the skin, colon, lung, breast, prostate, and kidney; patients should receive an annual comprehensive skin examination as the incidence of skin cancer in patients with CLL is very high.

Assessment and Diagnosis:

- Immunophenotyping of the circulating B cells is critical to establish the diagnosis by identifying the presence of a malignant clone of these cells; it is also used to gauge the prognosis.
- Other special cytogenic and molecular analyses (e.g., fluorescence in situ hybridization [FISH]) are also used to guide prognosis and therapy.
- Beta-2 microglobulin, a protein found on the surface of lymphocytes, can be measured in the serum; an elevated level correlates with a more advanced clinical stage and poorer prognosis.

Medical Management:

Various parameters are considered when treatment is selected, including the clinical stage of the disease, disease-associated symptoms, the functional status of the patient, genetic risk for poor prognosis, and the extent of any prior therapy and efficacy of that therapy.
Functional status is a complex consideration: in the context, it incorporates the individual's life expectancy independent of CLL (due to other health problems), the ability to tolerate aggressive therapy (creatinine clearance is particularly important), and the ability to perform ADLs.
- Good Functional Status: Can typically tolerate aggressive therapy and often achieve lasting complete remission.
- Impaired Physical Status: Objective of treatment focuses on controlling bothersome symptoms (e.g., drenching night sweats; painful lymphadenopathy).

Pharmacologic Therapy:

Combination Therapy: Using an immunotherapeutic antibody against CD20 with chemotherapy agents is typically given as initial therapy.
- When the disease is accompanied by a deletion of the TP53 gene or a mutation of this gene, the combination of chemo-immunotherapy is largely ineffective; however, two kinase inhibitors are now available that are efficacious in this extent.

Surgical Management:

Because of the older age of most patients with CLL, transplantation may not be an option, particularly if significant comorbidities exist.

# data[].attributes.headline
(3) Compare and contract chronic and acute lymphocytic leukemia to include incidence, clinical manifestations and prognosis

# data[].attributes.subject
(3) Compare and contract chronic and acute lymphocytic leukemia to include incidence, clinical manifestations and prognosis

# data[].attributes.headline
(1) A nurse is caring for a patient admitted for a syncopal episode. The patient has a history of severe hypoproliferative anemia & she is being evaluated for the same. 

# data[].attributes.subject
(1) A nurse is caring for a patient admitted for a syncopal episode. The patient has a history of severe hypoproliferative anemia & she is being evaluated for the same. 