Anatomic and Physiologic Overview• The hematologic system consist of the blood

and the sites where blood is produced, including the bone marrow and the reticulo endothelial system(RES).Blood is a specialized organ that differs from other organs in that it exists in a fluid state. Blood is composed of plasma and various types of cells. Plasma is the fluid portion of blood; it contains various proteins, such as albumin,globulin,fibrinogen,and other factors necessary for clotting, as well as electrolytes, waste products, and nutrients. About 55% 0f blood volume is plasma.

BLOOD

The cellular component of blood consist of three primary cell types:RBCs(red blood cells or erythrocytes),WBCs(white blood cells or leukocytes),and platelets(thrombocytes).These cellular components of blood normally make up 40% to 45% of blood volume. Because most blood cells have a short life span, the need for the body to replenish its supply of cells is continuous; this process is termed hematopoiesis.The primary site for hematopoiesis is the bone marrow. During embryonic development and in other conditions, the liver and spleen may also be involved.

Under normal conditions, the adult bone marrow produces about 175 billion RBCs,70 billion neutrophils(mature form of a WBC),and 175 billion platelets each day. When the body needs more blood cells, as in infection (when more RBCs are required.Thus,under normal conditions, the marrow responds to increased demand and released adequate numbers of Cells into the circulation.

The volume of blood in humans is approximately 7% to 10% of the normal body weight and amounts to 5 to 6L.Circulating through the vascular system and serving as a link between body or gans,the blood carries oxygen absorbed from the lungs and nutrients absorbed from the gastrointestinal tract to the body cells for cellular metabolism to the lungs,skin,liver,and kidneys, where they are transformed and eliminated from the body. Blood also carries hormones, antibodies,and substances to their sites of action or use.

To function, blood must remain in its normally fluid state. Because blood is fluid, the danger always exists that trauma can lead to loss of blood from the vascular system. To prevents this, an intricate clotting mechanism is activated when necessary to seal any leak in the blood vessels. Excessive clotting is equally dangerous, because it can obstruct blood flow to vital tissues. To prevent this, the body has a fibrinolytic mechanism that eventually dissolves clots (thrombi)formed within blood vessels. The balance between these two systems, clot (thrombus) formation and clot (thrombus) formation and clot (thrombus) dissolution or fibrinolysis,is called homeostasis.

LEUKEMIA

Definition:• Leukemia is a neoplastic

disorder of the blood-forming tissue, and primarily targets the spleen, lymph nodes, and bone marrow.

• “Cancer of the blood” and the most common form of childhood Cancer.

Literally “white blood”, is a neoplastic proliferation of one particular cell type (granulovytes, monocytes, lymphocytes,or megakaryocytes). The defect originates in the hematopeoitic stem cell, the myeloid, or the lymphoid stem cell. The lymphomas are neoplasm of lymphoid tissue, usually derived from B lymphocytes. Multiple myeloma is a malignancy of the most mature form of B lymphocyte, the plasma cell. The common feature of the leukemia’s is an unregulated proliferation 0f WBCs in the bone marrow. In acute forms (or late stages of chronic forms), the proliferation of leukemic cells leaves little room for normal cell production. There can also be a proliferation of cells in the liver and spleen (extramedullary hematopoiesis). With acute forms, there can be infiltration of other organs, such as the meninges, lymph nodes, gums, and skin. The cause of leukemia is not fully known, but there is some evidence that genetic influence and viral pathogenesis may be involved. Bone marrow damage from radiation exposure or from chemicals such as benzene and alkylating agents (eg, melphalan {Alkeran}) can cause leukemia.

Pathophysiology:• All types of leukemias result from the abnormal

development of leukocytes in the bone marrow. Maturational arrest occurs, and a proliferative, clonal population of cells result. A variety of defects promote the clonal expansion of leukemic cells. These defects include an abnormal proliferative potential, defects in terminal differentiation, and defective apoptosis. The increased proliferative potential is caused by the activation of oncogenes or the inactivation of tumor suppressor genes. Leukemia cutis is thought to result from a local proliferation of the leukemic cells within the skin.

The pathophysiology underlying the specific migration of leukemic cells to the skin is not clear. In the case of human T-cell leukemia virus type I (HTLV-I)–induced leukemia, it may be due to the abundant expression of the CC chemokine receptor 4 (CCR4) on the cell surface of the leukemic cells. The ligands thymus and activation-regulated chemokine (TARC/CCL17) and macrophage-derived chemokine (MDC/CCL22) are present in the skin and may explain the predilection of adult T-cell leukemia to involve the skin. Evidence also suggests that the presence of T-cell–related antigens on the cell surface of leukemic cells in acute monocytic leukemia (AML-M5) in patients with leukemia cutis may promote selective homing to the skin. Additionally, one small study of 18 cases of myelomonocytic leukemia cutis patients showed cutaneous lymphocyte-associated antigen (CLA) staining in 14 (78%) of 18 cases. The presence of CLA may confer a specific tropism to the skin in these leukemic cells.

ASSOCIATED MEDICAL CONDITIONS

1. Acute Myeloid Leukemia (AML)• AML, results from a defect in the

hematopoietic stem cell that differentiates into all myeloid cells: monocytes, granulocytes (neutrophils, basophils, eosinophils), erythrocytes, and platelets. All age group are affected; the incidence rises with age, with a peak incidence at age 60 years. AML is the most common nonlymphocytic leukemia.

Acute Myeloid Leukemia

Chronic myeloid leukemia (CML) arises from a mutation in the myeloid stem cell. Normal myeloid cells continue to be produced, but there is a preference for immature (blast) forms. Therefore, a wide spectrum of cell types exists within the blood, from blast forms through mature neutrophils.

2.Chronic Myeloid leukemia (CML)

Chronic Myeloid Leukemia

CHRONIC MYELOID LEUKEMIA

3.Acute Lymphocytic Leukemia (ALL) ALL results from uncontrolled proliferation of immature cells (lymphoblasts)derived from the lymphoid stem cell. The cell of origin is the precursor to the B lymphocyte in approximately 75%of ALL cases; T lymphocyte ALL occurs in approximately 25% of ALL cases.

4. Chronic Lymphocytic Leukemia (CLL) CLL is a common malignancy of older adults; two thirds of all patients are older then 20 years of age at diagnosis. It is the most common form of leukemia in the United States and Europe.

Chronic lymphocytic leukemia

• Fatigue

• Chronic malaise• Dizziness• Nosebleeds• Petechiae• Weight loss• Sensitivity /pain in

mid-sternal area, deep bone pain

• Hepato/Splenomegaly

• Anemia• Pallor• Fever (without infection)• Bleeding gums• Ecchymoses (easily bruised)• Anorexia• Marked increase in

immature leukocytes• Frequent infections

• Fear• Anxiety• Body temperature, high risk for altered• Pain• Powerlessness• Skin integrity, high risk for impaired• Infection, at high risk for• Body image disturbance• Fatigue• Nutrition: less than body requirements, altered• Physical mobility, impaired• Depression• Spiritual distress (distress of the human spirit)

PLANNING/ GOAL

• Protect from infection: standard precaution plus protective (reverse isolation.)

• Prevent injury: No aspirin, soft bristle toothbrush

• Promote Nutrition: High protein, high calorie, high iron diet, high fluids; small frequent feeding: monitor weight

• Relieve Pain : Supportive complementary and alternative approaches to pain management.

NURSING INTERVENTIONS• Provide adequate rest• Protect from falls trauma• Protective isolation• Administer blood / blood products• Provide appropriate oral hygiene• Force fluids, 3-4 liter / day• Constant monitoring for bleeding / hemorrhage • Administer stool softeners• Supportive therapy to patient / family

EVALUATION

• Experiences no bleeding.• Has intact oral mucous membranes.• Participates in oral hygiene regimen• Reports no discomfort in mouth• Attains optimal level of nutrition• Shows no evidence of infection.• Maintain weight w/ increased food and fluid

intake• Maintains adequate protein stores (albumin)

Reports satisfaction w/ pain and discomfort levelsHas less fatigue and increased activityMaintain fluid and electrolytes balanceParticipates in self-careCope w/ anxiety and grief

a.Discusses concerns and fearsb.Uses stress management strategies appropriately c.Participates in decisions regarding end-of-life care

Absence of complications

Treatment • Chemotherapy • Radiation therapy • bone marrow transplantation, either

allogeneic or autologous, to replace the bone marrow killed by chemotherapy or radiation. Legacy has a special program for bone marrow transplantation.

• Biologic therapy • In some cases, patients will undergo a

splenectomy (surgery to remove the spleen). The spleen is an organ in the lymphatic system.

REFERENCES

• Medical- Surgical Nursing• Brenda Goodner, R.N.,M.S.N.,C.S.• Brunner & Suddarth’s 10th Edition Volume1

Chemotherapy