It is a malignant disorder involving bone marrow dysfunction manifested by anemia, thrombocytopenia, and abnormal proliferation of white cells, which results in harmful filtration into tissues. It is the most common malignancy in childhood (30%), peak incidence 2-8 years of age. Incidence among males is greater than females’ 2:1.
Although the exact cause is unknown, but multiple factors believed to be responsible: ionizing radiation, chemicals (benzene compound, heavy metals), drugs (Alkylating agents), and chromosomal abnormalities (Down syndrome), and familial predisposition.
There will be a bone marrow failure resulted from overgrowth of leukemic cells in the marrow (immature blast cells).
Both red cells precursors and megakaryocytes from which platelets are formed are decreased leading to anemia and epistaxis, and easy bruisability.

Since white blood cells are decreased infection is common.
 Leukemic cells will proliferate (migrate out) of bone marrow and infiltrate in lymph nodes spleen, liver leads to Hepato-splenomegaly and lymphoadenopathy.
Leukemia is classified according to its predominant cell type and level of maturity as described by the following:

Lympho for Leukemias involving the lymphoid or lymphatic system.
 Myelo for those of myeloid (bone marrow) origin.
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Blastic and acute for those involving immature cells.
 Cytic and chronic for those involving mature cells.
In children two forms are generally recognized:
 Acute lymphoid leukemia (A.L.L.) and acute nonlymphoid leukemia
(A.N.L.L) or (A.M.L).
 A.L.L includes lymphatic, lymphocytic, lymphoblastic and lymphoblastoid leukemia.

A.N.L.L. type includes granulocytic, myelocytic, monocytic, myelogenous, monoblastic and monomyeloblastic.

It is according to the pathological effect:
Organ or Tissue
Bone Marrow
Dysfunction
Liver, Spleen and
Lymph gland
CNS Meninges
Consequences Manifestation
1. Decreased RBCs anemia.
2. Neutropneia infection.
3. Decreased bleeding tendancy.
Pallor, exertion.
Fever fatigue, dyspnea
(Petechia)
4. Invasion of bone marrow
bone weakness.
Tendency toward fractures.
5. Invasion of periosteum increase pressure.
1. Infiltration.
2. Enlargement.
3. Eventual fibrosis. intracranial 1. Increased pressure.
2. Ventricular enlargement.
3. Meningeal irritation. abdominal pain)
1. Hepatomegaly.
2. Splenomegaly.
3. Lymphoadenopathy.
1. Severe headache.
2. Vomiting.
3. Irritability.
4. Lethargy.
5. Papilledema.
6. Eventual coma.
7. Pain.
8. Stiff neck and back.
Hypermetabolism
1. Cell deprivation of nutrients by invading cells.
1. Lassitude.
2. Muscle wasting.
3. Weight loss.
4. Anorexia.
5. Fatigue.
6. Low-grade fever.
Leukemia is usually suspected by the history, physical manifestations and peripheral blood smear that contains immature forms of leukocytes, frequently combined with low blood counts. Definitive diagnosis is based on bone marrow is hypercellular with primarily blast cells. Once the diagnosis is confirmed, a lumber puncture is performed to determine if there is any C.N.S. involvement.

Treatment of leukemia involves the use of chemotherapeutic agents with or without irradiation in three phases:
1. Remission induction therapy : which is determined by the absence of clinical evidence of disease and the presence of less than 5% blast cells in the bone marrow.
2. C.N.S. preventive therapy and consolidation , which provides treatment in those areas of the body normally protected from cytotoxic, drug levels.
3. Maintenance therapy , which serves to maintain the remission phase.
In some children a fourth phase, reinduction therapy is needed to treat a relapse.
Almost immediately after confirmation of the diagnosis, induction therapy is begun and lasts 4 to6 weeks. The principal drugs used for induction in A.L.L. are:

Corticosteroids. (Especially Prednisone).
 Vincrisline Sulfate “ Oncovin”.
 Adramycin.
Treatment of the C.N.S consists of prophylactic therapy with intrathecal chemotherapy. This therapy is reserved for high-risk patients and those with
C.N.S. disease. C.N.S. therapy usually begins during the first 6 to 8 weeks after diagnosis and is continued for a specific period of time.
Once complete remission is obtained, a period of intensified treatment is administered to further reduce the leukemia burden (Consolidation).
Maintenance therapy is begun after completion of successful induction and consolidation therapy to preserve the remission and further lessen the number of leukemic cells.
When the presence of leukemic cells are observed in the bone marrow,
C.N.S. or other sites, the child has relapsed. Therapy for the child who has relapsed includes reinduction. Other drugs not previously used.
It has been used successfully for treating children who have A.L.L.. and
A.N.L.L. bone marrow transplantation is not recommended for children with
A.L.L. during the first remission because of the excellent results possible with

chemotherapy. Because of the poor prognosis in children with A.N.L.L. transplantation may be considered during the first remission.
The most important factors for determining long-term survival for children with A.L.L. in addition to treatment are:
1. The initial WBCs count.
2. The child’s age at the time of diagnosis.
3. The type of cell involved.
4. The sex of the child.
Children diagnosed between 2 and 9 years of age have consistency demonstrated a better outlook than those diagnosed before 2 or after
10 years of age, and females appear to have a more favorable prognosis than male.
1. High risk for infection related to depressed body defenses.
Goal:
Patient will experience minimized risk of infection.
Intervention:

Place child in private room.
 Advise all visitors and staff to practice hand washing.
 Screen all visitors and staff for signs of infection.

Use aseptic technique.
 Evaluate child for any potential sites or infections.
 Provide nutritionally complete diet for age.
 Administer antibiotics as prescribed.
Expected Outcome:
 Child doesn’t come in contact with infected persons or contaminated articles.
 Child consumes diet appropriate for age.
2. High risk for injury (hemorrhage) related to interference with cell proliferation.
Goal:
Patient will exhibit no evidence of bleeding.
Intervention:

Use all measures to prevent infection, especially in ecchymotic area.
 Use local measures to stop bleeding.
 Restrict strenuous activity that could result in accidental injury.

Involve child in responsibility for limiting activity when platelet count drops.


Administer platelets as prescribed.
Expected Outcome:
 Child exhibits no evidence of bleeding.
3. Altered nutrition less than body requirement related to loss of appetite.
Goal:
Patient will receive adequate nutrition.
Intervention:
 Encourage parents to relax pressure placed on eating.
 Allow child any food tolerated. Improve quality of food selections when appetite increases.
 Stress expected increase in appetite from steroid.
 Take advantage of any hungry period, sever small snakes.

Allow child to be involved in food preparation and selection.
 Make food appealing.
 Remember usual food practices of children in each age group.
Expected Outcome:

Nutrition intake is adequate.
4. High risk for fluid volume deficit related to nausea and vomiting.
Goal:
Patient will experience no vomiting.
Intervention:
 Administer initial dose of antiememtic before onset of nausea and vomiting.

Avoid foods with strong odors.
 Uncover hospital foo d tray outside of child’s room to reduce food orders.

Mouths care frequently.
Expected Outcome:
 Child retains food and fluids.
5. Altered mucous membranes related to administration of chemotherapeutic agents.
Goal:
Patient will not develop oral mucostis.
Intervention:
 Inspect mouth daily for oral ulcers, avoid oral temperatures.
 Oral hygiene as soon as a drug is used that caused oral ulcers.


Use soft sponge toothbrush, cotton tipped applicator or gauze wrapped finger.
 Administer frequent (at least every 4 hours and after meals) mouthwashes (normal saline or sodium bicarbonate solution).
 Apply local anesthetics to ulcerated areas before meals and as needed.
 Serve bland, moist, soft diet.

Encourage fluids; use a straw to help bypass painful areas.
 Report evidence of ulcers to doctor.
 Avoid juices containing ascorbic acid lemon swabs and hot or cold food.
 Administer antiinfective medication as ordered.
Expected Outcome:

Mucous membrane remains intact.
 Ulcer shows evidence of healing.
Goal: (2)
Patient will not develop rectal ulceration.
Intervention:
 Wash perineal area after each bowel movement.

Use warm bath or tub baths.
 Apply protective skin barriers (transparent film dressings, occlusive ointment) to perineal area.
 Obse rve constipation resulting from child’s voluntary refusal to defecate or from chemotherapy.
 Avoid rectal temperature and suppositories.
 Record bowel movement, use stool softener to prevent constipation.
Expected Outcome:

Rectal mucosa remains clean and intact.
 Ulcerated areas heal without complications.
 Child has regular bowel movements.
6. Impaired skin integrity related to administration of chemotherapeutic agents.
Goal:
Patient will maintain skin integrity.
Intervention:

Provide skin care especially in mouth and perineal regions.
 Change position frequently.
 Encourage adequate caloric-protein intake.
Expected Outcome:
 Skin remains intact.
7. Pain related to diagnosis and treatment.
Goal:

Patient will experience minimal or no pain.
Intervention:
 Avoid excessive noise or light.
 Place all commodities with easy reach.
 Use gentle, minimal physical manipulation.

Avoid pressure on painful relief from analgesics.
 Experiment with using heat or cold on painful areas (Use cautiously because of easy skin breakdown).

Change position frequently, if difficult for child coordinate with pain relief from analgesics.
 Avoid pressure on bony prominences.
 Administer analgesics as prescribed.
 Avoid aspirin or any of its compounds.
Expected Outcome
 Child rests quietly, exhibits no evidence of discomfort verbalizes no complaints of discomfort.
8. Body image disturbance related to loss of hair and moon face.
Goal: (1)
Patient will exhibit positive coping.
Intervention:
 Administer good scalp hygiene.
 Provide adequate covering during exposure to sunlight, wind or cold.
 Stress that hair begins to regrow in 3 to 6 months and may be a slightly different color or texture.
Expected Outcome:
 Child verbalizes concern regarding hair loss.

Child appears clean, well groomed and attractively dressed.
Goal: (2)
Patient will exhibit adjustment to altered facial appearance.
Intervention:
 Stress that this reaction is temporary.
 Evaluate weight gain carefully.
 Encourage early and consistent interaction with peer.
Expected Outcome:
 Child resumes former activities and relationship within capabilities.
9. Fear related to diagnostic tests, procedures, treatment, and prognosis.
Goal:
Patient will exhibit reduced fear related to diagnostic procedures and tests.
Intervention:

 Explain procedure carefully at child’s level of understanding.
 Explain responsibility of child.
 Provide child with some means of involvement with the procedure.
 Implement distracting technique and pain reduction techniques as indicated.
Expected Outcome:
 Child readily responds to verbal directives and exhibits less fear.
 Child repeats information accurately.
10. Altered family process related to a child with life threatening disease.
Goal:
Family will receive adequate support.
Intervention:
 Teach parents about disease process.
 Explain all procedures that will be done to child.
 Schedule time for family to be together.
 Help family for future, especially toward helping child live a normal life.
 Encourage family to discuss feelings regarding child’s course prior to diagnosis and child’s prospects for survival.
 Discuss with family how they will tell child about outcome of the disease.
Expected Outcome:
Family expresses feelings and concerns and spends time with child