PEDIATRIC NURSING ROUNDS

ACUTE LYMPHOBLASTIC LEUKEMIA: RELAPSE

By: Beza Fissaha

CLIENT HISTORY

RM is a 20 year old Hispanic female with a history of high risk pre-B cell ALL
RM was diagnosed with ALL at the age of 16 and received treatment until 20
years old.
RM was hospitalized for fever and neutropenia and was sent home on Cefepime
after one week of hospitalization
RM presented to the ED with fever after 1 day of being discharged (February
24,2016).

CLIENT HISTORY

RM presented to the ED with fever after 1 day of being discharged (February

24,2016).
RM was admitted to the CHKD ED with fever/neutropenia on February 25,2016
RM states that she initially felt well when she first got home but became
increasingly fatigued through the evening. She began having chills and checked
her temperature; 99.9F
Temp increased to 101.4 the following morning
Primary Medical Diagnosis: High risk pre-B ALL, Relapsed
Secondary Medical Diagnosis: Neutropenia

HIGH RISK PRE-B ALL

Pathophysiology of ALL
A L L i s c a u s e d by g e n e t i c a l te r a t i o n s o f t h e l y m p h o i d
p r o g e n i to r c e l l s . T h i s c a u s e s p r o l i fe r a t i o n a n d
u n c o n t r o l l e d c l o n a l ex p a n s i o n . T h e l e u ke m i c b l a s t s
i n f i l t r a te t h e b o n e m a r r ow a n d g r a d u a l l y i n f i l t r a te
o t h e r o r g a n s . T h i s i n te r fe r e s a n d d i s r u p t s n o r m a l
f u n c t i o n o f t h e o r g a n s a n d l e a d s to t h e d eve l o p m e n t
o f A L L . T h e n o r m a l l y m p h o i d p r o g e n i to r i s a l te r e d
a s t h e l u ke m i c c e l l s d u p l i c a te s m o s t o f i t s fe a t u r e s .
ALL also causes chromosomal abnormalities and
lesions. In most cases, chromosomal translocations
a l s o o c c u r.

Treatment Plan
Complete cycle 1 of Blinatumomab
experimental therapy
Monitor for side effects of the
experimental therapy
Neuro Assessments q4h

https://www.youtube.com/watch?
v=lCRePFf4zNs&list=PLir3rm78Vl2mdayBsVtsTYTuwxluxB7j3

Psychosocial considerations
(Bhojwani,Howard,&Pui, 2009)

Monitor for fever / prevent infection

HIGH RISK PRE-B ALL: RELAPSE

v Although majority of children with ALL have a high cure rate, certain subsets have a high risk
of relapse
v Risk of relapse can be predicted by the patients response to therapy, clinical/
pharmacokinetic features of the host, and the general genetic characteristics of the
leukemic cells
v Certain factors are usually used to determine which risk group the child falls into; age at
diagnosis and initial WBC count are the common predictors considered
v Children with pre-B or early pre-B-cell ALL usually have better prognosis than mature B-cell
(Burkitt) leukemia.
(Williams et al.,2014)

SECONDARY DIAGNOSIS: NEUTROPENIA

Pathophysiology
Neutropenia is the reduction in the bloods
neutrophil count; if severe enough, the risk
of developing bacterial and fungal infections
become significantly increased. Neutrophils,
also known as granulocytes, are the bodys
defense system against dif ferent types of
infections. In the presence of neutropenia,
the regular inflammator y response to
infection is not ef fective. In the presence of
another factor (such as cancer), acute
neutropenia can significantly impair the
immune system and cause fatal infections.

Treatment Plan
Prevent Infection
Monitor for signs of Infections
Monitor WBC/CBC counts

(Bar tels, Murphy, Rieter, & Bruin, 2015)

Monitor Temperature

CULTURAL CONSIDERATIONS
Hispanic
Family support
School age/adolescent
Body image
View of Healthcare

DEVELOPMENTAL STAGE
Adolescent/Young Adulthood
Erikson
Identity vs Role Confusion
Social relationships
Nursing Implications

Piaget
Cognitive development
Assimilation
Accommodation

Nursing Implications

RM is not age appropriate and

does not fully meet the
developmental norms for her age
group
Flat affect
Discouraged
Depression
Has missed more than 2 years of
school since her Dx at 16

DEVELOPMENTAL THEORY RELATED TO CARE

RM is a 22 year old female. According to Eriksons developmental
theory, she would be at the stage of young adult hood. At this stage,
the person experiences the struggle of Intimacy Vs. Isolation.
The most important event in this stage is romantic attachment or
relationships. If successful at this stage, the person finds intimacy
and has significant relationships with friends. If this is not resolved,
the person might experience isolation.
However, this stage is only possible if the person has overcome the
stage battle of the adolescence years; Identity vs Role confusion. Role
confusion can be a result of depression (which this patient has),
feeling different, and rebellion. If this stage is not mastered with
identity, the individual does not progress to the stages of adulthood.

DEVELOPMENTAL THEORY RELATED TO CARE

The patient was diagnosed with ALL at 16 y.o, spending the majority of her time in
the hospital. The phase of adolescence has most likely not been accomplished thus
preventing her progression to young adulthood.
This time can significantly impact health and illness as it can contribute to how the
adolescent view themselves. This is the stage for body image concern and the desire
to be normal and not signaled out.
During this time period health and illness may have crucial impact on how an
adolescent perceives their self especially in the case of a chronic disease such as
asthma.
Nursing care should encompass support, empathy, and understanding
Appropriate care for this age group includes educating families, listening,
encouraging patient to express feelings, providing independence and privacy, and
promoting relationships.

PHYSICAL ASSESSMENT DATA

Neuro
Periodic right eye pain, HA, Dizziness

Genitourinary
Nausea, Abdominal Pain

Heme/Onc
Continued pancytopenia

Psychosocial
Depression, flat affect

1. Risk For Infection

Related to: Impaired /compromised immune

system, chemotherapy induced marrow
suppression

As evidenced by: Malnutrition,

Invasive procedures (central line placed),
consistent occurrence of fever, low WBC count
WBC count: 1.3 10e3/microliter

Meds: Acetaminophen, amphotericin B,

Clindamycin

CONCEPT MAP
Pt Initials: RM
Age: 20
Medical Diagnoses:
1. High risk pre-B ALL
(Relapsed)
2. Neutropenia

2. Acute Pain
Related to: Disease process
As evidenced by Reports pain level of 7, nausea,
headache
Keppra, ondasteron, ativan, scopolamine
Patient reports pain level acceptable to her baseline

4. Fatigue

Patient will remain afebrile for remainder of hospital stay

3. Nausea
Related to: Effects of chemotherapy
As evidenced by patient report of nausea, patient
report of dizziness, and chemotherapy treatment for
ALL
Meds: ondasteron, scopolamine

Related to: decreased

metabolic energy production,
side effect of chemotherapy,
overwhelming psychological/
emotional demand.

5. Fear/ Anxiety

As evidenced by lack of
energy, loss of 10lbs in 1
month, lethargy, disinterest in
surrounding

As evidenced by depression, flat affect, decreased use

of social support, desires isolation

Patient will report a decrease in nausea

Family will express concerns, and
exhibit less stress related to
hospitalization

Related to situational crisis (cancer), threat to death,

separation from role development, consistent
hospitalization

Zoloft, ativan
Patient will exhibit less fear and tearfulness

ACTUAL VS. POTENTIAL PROBLEMS

A ctual Problems
Risk For Infection

P otential Problems
Fever
R/T: Increased temperature

Acute Pain
Impaired physical mobility
R/T: inability to perform movements
without the presence of pain

Anxiety
R/T: fear of death

HOLISTIC CARE

Teaching and promoting relaxation techniques

Promoting use of spiritual practice
Administering pain medications as prescribed
Performing a thorough assessment
Providing care with a interdisciplinary approach
Providing encouragement, praise, and support
Provide adequate care related to any other alternative therapies

EXPERIMENTAL THERAPY: BLINATUMOMAB

Blinatumomab therapy
Pa t i e n t o n C yc l e 1 o f t h e r a py
28 days
15 micrograms/m2/day
C o n c e r n s o f t h i s d r u g
Fever/ sepsis
Hypoxia
Pulmonary edema
Capillary leak syndrome
Cytokine release syndrome

Adverse Ef fects of Blinatumomab therapy

S i d e e f fe c t : Pe a k i n c i d e n c e a t 24 h o u r s
C y to k i n e r e l e a s e s y n d r o m e , 1 2 - 7 2 h r o n s e t
Fever, flushing, hypotension
Resembling septic bacteremia
O t h e r s i d e e f fe c t s
Confusion, somnolence, combativeness
Seizures
BIGGEST CONCERN: NEURO TOXTICITY

G i ve n i n a d j u n c t w i t h c h e m o t h e r a py
Intrathecal Tripple Therapy
Methotrexate (MTX)-15mg
Hydrocortisone (HC)-15mg
Cytarabine (ARAC)-30mg

https:// www.youtube .com/ watc h? v= z E 4JG gVLbVQ

EXPERIMENTAL THERAPY: BLINATUMOMAB

RM EXPIREINCE WITH THERAPY
R M a d ve r s e e f fe c t s
20 hour into blinatumomab therapy, RM strikes a
fever (39.7 c)
RM feels achy, has chills and is fatigued, 02 sats
below 90; 02 support required
RM reports feeling SOB, crackles heard on right
lower lobe on exam

NURSING MANAGEMENT FOR BLINATUMOMAB THERAPY

D a i l y N e u r o tox i c i t y A s s e s s m e n t
Daily handwriting sample could predict future nervous system
toxicity before the clinical toxicity develops
A daily finger-nose-finger or writing sample test is
recommended according to age-appropriate activities for
patients.
If change noted in finger-nose-finger or handwriting test-it is
recommended to start dexamethasone
V i t a l s i g n s Q 4 h o u r s
S TO P i n f u s i o n O N LY fo r eve n t o f a s e i z u r e
Interruptions require significant MD intervention and
documentation

TEACHING AND DISCHARGE PLANNING

Teaching
Infection prevention
Identifying signs and symptoms
that requires medical attention
Understanding importance of
finishing antibiotic treatment
and adhering to medication
regimen
Rest, reduce stress

Discharge Planning
Informing Client about follow up
visits
Providing additional resources as
well as possible schedules for
chemotherapy
Encouraging expression of any
concerns
Addressing any questions that
patient and family has on
physician instructions

RESEARCH
Adolescents Psychosocial Health-Related Quality of Life Within 6
Months After Cancer Treatment Completion
Objective of study
Health- related quality of life can be af fected in the pediatric
patient post cancer treatment
Risks that compromises health-related quality of life in the
adolescent patient dealing with cancer
Impact of cancer treatment
Study Results
(Ruccione, Lu,& Meeske,201 3)

RESEARCH
IMPLICATIONS ON NURSING
Identifying protective and risk factors
Potential intervention

Providing support, comfort, and understanding

Actual intervention

REFERENCES
Bhojwani, D., Howard, S. C., & Pui, C. (2009). High-Risk Childhood Acute Lymphoblastic
Leukemia.Clinical Lymphoma and Myeloma,9. doi:10.3816/clm.2009.s.016

K. R. (201 3). Adolescents Psychosocial Health-Related. Cancer Nur sing, 36(5), 61-71 .
doi:http://journals.lww.com/cancernur singonline/Abstract/2013/09000/Adolescents
Ruccione, K., Lu, Y., & Meeske, K. (201 3). Adolescents Psychosocial Health-Related Quality of Life
Within 6 Months Af ter Cancer Treatment Completion.Cancer Nur sing,36(5).
doi:10.1097/ncc.
0b01 3e31 82902119

Williams, M. T., Yousafzai, Y., Cox, C., Blair, A ., Carmody, R., Sai, S., . . . Halsey, C. (2014). Interleukin15 enhances cellular proliferation and upregulates CNS homing molecules in pre-B acute
lymphoblastic leukemia.Blood,1 23(20), 3116-31 27. doi:10.11 82/blood-201 3-05-49997

THE END

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