Nursing Care of

Child with
Thalassemia
and Leukemia
Fong Jia Yu Janice U2004186/1
Eleena Sofea Binti Nor Azmi 17203465
 Table of contents
Diagnosis &
01 Definition 05 Investigations

02 Etiology
06 Treatment

03 Clinical
Manifestations 07 Complications

Nursing
04 Pathophysiology 08 Management

2
LEUKEMIA

3
 Definition

● Malignant transformation and proliferation of white blood

cells that occurs in the red bone marrow
● Most common form of childhood cancer
4
 Types of childhood leukemia

Acute leukemia Chronic leukemia

Acute Acute Chronic Juvenile

lymphoblastic myelogenous myelogenous myelomonocytic
leukemia (ALL) leukemia (AML) leukemia (CML) leukemia (JMML)

5
 Acute lymphoblastic Acute myelogenous leukemia
leukemia (ALL) (AML)

Most common form Too many

Makes up about
of childhood 2-5 years of age myeloblasts are
20% of childhood
leukemia (75-80%) produced in the
leukemia cases
bone marrow

Affects
lymphoblasts Good prognosis Down syndrome
(immature (80% survival children has a 50 Associated with
lymphocytes - B & rate) fold increase in toxic exposures
T cells) risk for AML

6
 Chronic myelogenous Juvenile myelomonocytic
leukemia (CML) Leukemia (JMML)

Incidence Rare and most

increases through commonly affects
Rare in children Unknown etiology
childhood / children under age
adolescence of 4

Myelomonocytic
Translocation
Uncontrolled cells are
between ch9 and
growth of myeloid overproduced and
ch22 - Philadelphia
cells invade the lungs,
chromosome
spleen and
intestines

7
 Etiology
● Genetic changes in the DNA of bone marrow cells
● The exact cause of most cases of childhood leukemia is not known.

● Risk factors :
1. Having siblings with leukemia
2. Congenital disorders such as Down
syndrome - increases the risk for 10-20
times
3. Exposure to radiation - leukemia can
develop as a secondary cancer
4. Maternal alcohol consumption
8
Pathophysiology

9
 Pathophysiology

Acute

Chronic

10
 Symptoms of leukemia
● Pallor
● Fatigue and lethargy
● Mouth ulcers
● Fever
● Frequent infections
● Easy bruising and bleeding (bleeding
gums, petechiae, recurrent nose
bleeds)

11
 Symptoms of leukemia

● Bone and joint pain

● Loss of appetite
● Tachypnea (mediastinal mass)
● Lymphadenopathy
● Hepatosplenomegaly
● Testicular enlargement in boys

12
 Diagnosis & Investigations
1. Complete blood count

● NCNC Anemia
● Leukocytosis
● Thrombocytopenia
● Neutropenia
● Blast cells present in acute leukemias
● In CML: marked hyperleukocytosis
with normal myeloid precursors

13
 Diagnosis & Investigations
2. Bone marrow aspiration/biopsy

● To identify the type of cancer by

cytology
● >30% leukemic blast cells

3. Lumbar puncture

● To inspect for the spread of leukemia

cells in the CSF (CNS involvement)

14
 Diagnosis & Investigations
4. Chest X-ray

● Mediastinal mass (in T-ALL)

15
 Treatment
Chemotherapy Radiation therapy

● Uses chemicals to interfere with ● Uses various types of radiation to

the cancer cells ability to grow kill cancer cells
and reproduce

● Can be used alone / in

combination with other therapies

● Can be given as a pill to swallow

orally / an injection into fat or
muscle / intravenously into the
bloodstream / into the spinal
column
16
 Treatment
Targeted therapy Stem cell transplant
● Use of medication that ● Abnormal blood-forming calls
specifically kills cancerous cells (leukemia calls) or cells that were
destroyed by chemotherapy are
● Eg: tyrosine kinase inhibitors
replaced by healthy new
(TKIs), monoclonal antibodies and
blood-forming cells
proteasome inhibitors
● Can be done by obtaining cells
from bone marrow, blood or
umbilical-cord blood

● Can be autologous or allogenic

17
 Treatment
Subtype Therapy
ALL ● Multiagent chemotherapy for 2 - 3.5 years
● Prophylactic intrathecal chemotherapy +/- radiation to
sanctuary sites

AML ● Multiagent intensive chemotherapy (6 - 9 months)

● Hematopoietic stem cell transplant

CML ● Single agent therapy with tyrosine kinase inhibitors

(Imatinib)
● Hematopoietic stem cell transplant if poor response

JMML ● Hematopoietic stem cell transplant

18
 Complications
Infection Organ malfunction

● Immature white blood cells are ● Hemorrhage occurs when

not fit to defend the body against immature white blood cells spill
pathogens into the bloodstream and other
tissues, eventually lead to organ
● The blood doesn’t have enough
or tissue malfunction.
immunoglobulins

19
Nursing Management
The care plan for leukemic patient emphasizes comfort,
minimize the adverse effects of chemotherapy, promotes
preservation of veins, manage complications as well as
provide teaching and psychological support.

20
 Nursing Diagnosis
1. Risk for infection related to overproduction of immature white blood cells.
2. Imbalanced nutrition: less than body requirements related to consequences of
chemotherapy for leukemia as evidenced by unintentional weight loss, loss of
appetite, nausea and vomiting.
3. Activity intolerance related to generalized weakness, anemia and increased
metabolic rate from massive production of leukocytes as evidenced by verbal
report of fatigue or weakness and lack of effort when standing or engaging in
activities.
4. Risk for bleeding related to thrombocytopenia.

21
 Nursing Diagnosis
6. Risk for deficient fluid volume related to excessive losses through vomiting and
diarrhea.

7. Risk for impaired skin integrity related to toxic effects of chemotherapy, alteration
in nutrition and impaired mobility.

22
 1. Risk for infection
Assessment Diagnosis Goals/ Nursing Interventions Rationale Evaluation
Outcome

Objective Risk for Short term Place the patient in a To protect patient
data: infection goal: private room and limit from potential
- related to Patient is free visitors. (I.I) sources of infection.
overproduction from infection
Subjective
of immature throughout
data: Monitor the patient’s Progressive
white blood hospitalization.
- temperature closely. (I.I) hyperthermia may
cells.
Long term occur in some
goal: infections and fever
Parents are able is common in
to demonstrate leukemia patients.
ways to prevent
Educate the parents and Prevents
infections and
visitors to practice good cross-contamination
recognize signs
hand hygiene protocol and reduces risk for
of infection upon
when entering the infection.
discharge.
patient’s room. (I.I) 23
 1. Risk for infection
Assessment Diagnosis Goals/ Nursing Interventions Rationale Evaluation
Outcome

Avoid or limit invasive Break in skin could provide

procedures such as an entry for bacteria and
venipuncture and injections pathogens. Use of central
as possible. (I.I) venous lines can reduce
the need of frequent
invasive procedures and
the risk for infection.

Encourage the parents to Proper nutrition enhances

provide nutritious diet high the immune system.
in protein and calories to
the child. (I.I)

Educate the parents to To minimize the potential

avoid raw fruits, vegetables sources of bacterial
and uncooked meat. (I.I) contamination.
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 1. Risk for infection
Assessment Diagnosis Goals/ Nursing Interventions Rationale Evaluation
Outcome

Change the patient’s Promotes cleanliness of Short term goal

diapers once it is soaked perianal area can was met.
and promote good perianal reduce the risk of Patient is free
hygiene to ensure the skin perianal abscess that from infection
is clean and dry. (I.I) may contribute to throughout
infection. hospitalization.

Administer antibiotics as Antibiotics may be given Long term goal

prescribed. (D.I) prophylactically or to was met.
treat specific infection. Parents were
able to
Educate the parents and Early identification of the
demonstrate
caregiver on the signs and presence of an infection
ways to prevent
symptoms of infection such can increase the
infection and
as fever, chills and sweats. effectiveness of
recognize signs
(I.I) treatment.
of infection. 25
 2. Imbalanced nutrition: less than body requirements
Assessment Diagnosis Goals/ Nursing Rationale Evaluation
Outcome Interventions

Objective Imbalanced Short term goal: Weigh the patient Allow the
data: nutrition: less Patient will routinely. (I.I) healthcare team to
Weight loss, than body consume adequate have objective
nausea and requirements nutrition in data to trend and
vomiting related to accordance with monitor the
consequences his/her needs after patient’s progress.
Subjective
of 3 days.
data: Explore the patient’s To create a
chemotherapy
Mother Long term goal: daily nutritional intake baseline of the
for leukemia as
reports that Patient will be able and food habits such patient’s nutritional
evidenced by
the child has to achieve a weight as meal time, duration status and
unintentional
no appetite to within his/her of each meal session preferences.
weight loss, loss
eat normal BMI range. and snacking. (I.I)
of appetite,
nausea and
vomiting.
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 2. Imbalanced nutrition: less than body requirements
Assessment Diagnosis Goals/ Nursing Interventions Rationale Evaluation
Outcome

Provide good oral hygiene. Good oral hygiene can

(I.I) increase the child’s
appetite.

Administer antiemetics as To reduce nausea and

prescribed. (D.I) vomiting caused by
chemotherapy and thus
allow increase in appetite
and tolerate intake better.

Refer the patient to the To provide a more

hematology/oncology specialized care for the
dietician. (C.I) patient in terms of nutrition
and diet.

27
 2. Imbalanced nutrition: less than body requirements
Assessment Diagnosis Goals/ Nursing Rationale Evaluation
Outcome Interventions

Educate the parents Allow parents to gain Short term goal was
on their child’s body knowledge on how to met. Patient consumed
nutritional needs. (I.I) prepare food to meet adequate nutrition in
nutritional needs accordance with
upon discharge. his/her needs after 3
days.
Provide patient with To meet the body’s
additional snacks in extra nutritional Long term goal was
between meals. (I.I) needs. met. Patient achieved
Encourage parents to To increase appetite a weight within his/her
bring food from home and food intake. normal BMI range.
according to the
child’s preferences.
(I.I)

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THALASSEMIA

29
 Thalassemia
● A group of hereditary blood disorder
● Patient cannot produce sufficient adult hemoglobin
● Red blood cells are abnormal in size and are rapidly
destroyed
● Affects approximately 4.4 out of every 10,000 live
births throughout the world
● Occur from spontaneous mutations
● Both males and females inherit the relevant gene
mutations equally because it follows an autosomal
pattern of inheritance with no preference for gender

30
 Etiology
● Group of hereditary anemia associated with defective synthesis of the
Hemoglobin
● Reduced production of one or more globin chain which leads to:

Hypochromia Haemolysis

Extreme
Microcytosis

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 Risk factors

Mutation or defect
Family history
in gene

Genetic

32
 Structure of Hemoglobin

● Four subunits
○ two 𝛂
○ two 𝜷
● Iron
● Heme
● Binds 4 molecules of
oxygen

33
 Pathophysiology
Disturbance of Decrease
Formation of
Due to ejection ratio between 𝜶 production of one
abnormal Hb
fraction and 𝞫 globin chain or more globin
structure
synthesis chains

Extramedullary Excessive RBC Ineffective

Iron overload
hematopoiesis destruction erythropoiesis

Thalassemia

34
 Thalassemia

Thalassemia Minor
Thalassemia Thalassemia Major
(Alpha/Beta
Intermediate (Cooley’s Anemia)
Thalassemia)

Thalassemia minor
Occurs when a child progressing to Occurs when a child
receives the faulty gene thalassemia major inherits the gene defect
from only one parent from both parents

35
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37
38
Clinical Manifestations
● Severe anemia
● Pale appearance
● Anorexia
● Jaundice
● Delay growth and puberty due to
anemia
● Weak bone - abnormal facial bone
● Infection
● Iron overload
● Enlargement of spleen, liver, heart
● Dark urine
39
40
 Diagnosis
● Family history of thalassemia
● Blood tests - FBC, microscopic analysis
● Hemoglobin electrophoresis
● Mutational analysis
● Radiographic bone growth studies
● Prenatal screening & diagnosis
● Genetic counselling

41
 Normal Values

Red Blood Male: 4.35 - 5.65 million cells/mcL

Cell Count Female: 3.92 - 5.13 million cells/mcL

Male: 13.2 - 16.6 g/dL

Hemoglobin
Female: 11.6 - 15 g/dL

Direct (Conjugated) = 0 - 0.3 mg/dl

Bilirubin Indirect (Unconjugated) = 0.1 - 1 gm/dl
Total = less than 1.5 gm/dl

Male = 65 - 175 mcg/dl

Serum iron
Female = 50 - 170 mcg/dl

42
43
44
 Assessment

Thalassemia Minor
Thalassemia Thalassemia Major
(Alpha/Beta
Intermediate (Cooley’s Anemia)
Thalassemia)

Assess for mild anemia Assess for anemia, Assess for severe anemia,
usually with no signs or jaundice, and splenomegaly or
symptoms. splenomegaly, hepatomegaly with
hemosiderosis caused by abdominal enlargement,
increased intestinal frequent infections,
absorption of iron. bleeding tendencies e.g.
epistaxis, and anorexia.

45
 -

Management
Main goal:
1. Blood transfusion
● Major thalassemia management
Maintain Hb
● Required in every 2-3 weeks to supplement RBCs and
levels at 9.5 g/dL
to prevent
maintain Hb level.
overgrowth of ● Complication: Excessive deposits of iron may be stored in
bone marrow and the tissues (hemosiderosis)
resultant
deformities 2. Iron chelation therapy
Provide for ● To prevent iron overload
growth and ● Deferasirox (Exjade): given orally once a day / can be toxic to
development and kidneys
normal physical ● Deferiprone (Ferriprox): given orally 3 times a day
activity ● Iron chelators that free iron in the blood and cause it to be
eliminated through the urine.

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47
-

Management
3. Supplements
● Folic acid supplements to enhance production of healthy
RBCs
● Antimetabolite, hydroxyurea to increase normal Hb
production
● Complication: Red discoloration in urine & blurred vision

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-

Management
4. Surgery
● Bone marrow transplantation
● Splenectomy

49
 Complications

Heart Disease Liver Disease Endocrine

problems

Delay growth Osteoporosis Thrombophilia

50
 Nursing Care

● Adhere to the principal of ● Emotional health of child and

long-term care parents
● Observation of patient during ● Attempt to ease the strain of
blood transfusion the prolonged illness
● Close monitoring and ● Home care arrangements,
nutritional support for Cooley’s Anemia Foundation
complications caused by (support and education)
excess iron deposit
● Self-esteem towards body
● Vital signs monitoring to changes caused by disease
detect irregularities of the
heart
51
 List of Nursing Diagnosis
#1 Ineffective tissue perfusion related to reduced cellular components that are essential
to deliver pure oxygen to the cells as evidenced by cyanosis and restlessness.

#2 Activity intolerance related to low hemoglobin and imbalance of oxygen supply and
demand secondary to thalassemia as evidenced by extreme fatigue and increased
respiratory rate of 26 breaths per minutes on exertion.

#3 Imbalanced nutrition less than body requirements related to lack of appetite as

evidenced by weight loss and decreased skin integrity.

#4 Ineffective family coping related to impact of the disease to family functioning.

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 #Ineffective tissue perfusion
Assessment Diagnosis Goals/ Nursing Interventions Rationale Evaluation
Outcome

Objective data: Ineffective tissue Short term goal: Patient 1. Monitor sign of hypoxia To serve as benchmark Short term
-Capillary refill perfusion related to will maintain oxygen such as cyanosis, for comparison in the goal met.
reduced cellular future.
less than 2 saturation above 95% hyperventilation, Patient
seconds components that without showing signs increased pulse, maintains
-Cyanosis are essential to and symptoms of respiratory rate and blood oxygen
-Oxygen deliver pure oxygen hypoxia after 3 days of pressure, capillary refill. (I.I) saturation
saturation 90% to the cells as intervention. above 95%
evidenced by without
cyanosis and 2. Monitor strict intake and To monitor fluid
Long term goal: balance of patient. showing signs
Subjective data: restlessness. output chart. (I.I)
Patient will show no Helps to maintain and
-Shortness of further deterioration and proper filling pressures symptoms of
breath maintain maximum and maximizes the hypoxia after
-Restlessness tissue perfusion to vital amount of cardiac
3 days of
output required for
organs as evidenced by intervention.
tissue perfusion.
warm and pink skin and
vital within normal
ranges after a week.
53
 #Ineffective tissue perfusion
Assessment Diagnosis Goals/ Nursing Interventions Rationale Evaluation
Outcome

Objective data: Ineffective tissue Patient will maintain 3. As tolerated, place To enhance alveolar Long term
-Capillary refill perfusion related to oxygen saturation patient in a semi-to gas exchange as these goal met.
reduced cellular Fowler’s high position. (I.I) positions will expand
less than 2 above 95% without Patient shows
lungs for patient to
seconds components that showing signs and no further
breathe optimally.
-Cyanosis are essential to symptoms of hypoxia deterioration
-Oxygen deliver pure oxygen after interventions. and maintain
saturation 88% to the cells as maximum
evidenced by tissue
cyanosis. 4. Transfuse blood To replace Hb levels
perfusion to
accordingly as ordered by that is currently low
Subjective data: vital organs as
the physician. (D.I) due to blood cells
-Shortness of destruction secondary evidenced by
breath to thalassemia. warm and pink
-Restlessness skin and vital
5. Administer iron chelation To balance the rate of within normal
therapy as prescribed by iron accumulation from ranges after a
physician. (D.I) cycles of blood
week..
transfusion.

54
 #Activity intolerance
Assessment Diagnosis Goals/ Nursing Interventions Rationale Evaluation
Outcome

Objective data: Activity intolerance Short term goal: 1. Assess the capability of Provides baseline Short term
- Respiratory related to low Patient and parents will doing activity. (I.I) information for goal met.
hemoglobin and formulating nursing
rate of 26 express patient’s ability Patient and
goals during goal
breaths per imbalance of to perform activities of family
setting.
minute oxygen supply and daily living and will be expressed
demand secondary able to use energy 2. Check and monitor Activity intolerance patient’s ability
- Tachycardia to thalassemia as patient’s vital signs such and decreased
conservation techniques to perform
evidenced by as blood pressure, oxygen saturation are
Subjective data: after 3 days of activities of
extreme fatigue and respiratory rate and common in patients
-Mother reports interventions. oxygen saturation level. with low hemoglobin daily living and
increased
child is more (I.I) level. will be able to
respiratory rate of
tired than usual Long term goal: use energy
26 breaths per 3. Create a schedule to Motivation and
Patient and parents will conservation
minutes on exertion. perform the activities cooperation are
express understanding techniques
according to client’s enhanced if the
about the different capability. (I.I) patient participates in after 3 days of
methods to decrease goal setting. interventions.
activity intolerance after
a week of interventions.
55
 #Activity intolerance
Assessment Diagnosis Goals/ Nursing Interventions Rationale Evaluation
Outcome

Objective data: Activity intolerance Short term goal: 4. Stop any activities if Fatigue can limit the Long term
related to low Patient and parents will pulse, blood pressure, patient’s ability to goal met.
hemoglobin and respiration rate, fatigue or perform needed
express patient’s ability Patient and
Subjective data: dizziness increases beyond activity.
imbalance of to perform activities of parents
-Fatigue normal rate. (I.I)
oxygen supply and daily living and will be expresses
demand secondary able to use energy understanding
to thalassemia as conservation about the
evidenced by techniques after 3 days different
extreme fatigue and 5. Provide frequent rest To reduce oxygen
of interventions. periods. (I.I) consumption to avoid methods to
increased
fatigue. decrease
respiratory rate of
Long term goal: activity
26 breaths per
Patient and parents will intolerance
minutes on exertion.
express understanding 6. Record and document Guide for the optimal after a week
about the different patient’s response to progression of the of
activities. activity and condition.
methods to decrease interventions.
activity intolerance
after a week of
interventions. 56
 Exercises
Which of the following would the nurse identify as the initial priority for the
child with acute lymphocytic leukemia?
A. Instituting infection control precautions
B. Encouraging adequate intake of iron-rich foods
C. Assisting with coping with chronic illness
D. Administering medications via IM injections

57
 Exercises
The long-term complications seen in Thalassemia major are associated to
which of the following?
A. Anemia
B. Growth retardation
C. Hemochromatosis
D. Splenomegaly

58
References
● Anna C. RN, B.S.N. (2022) Leukemia nursing diagnosis and nursing care plan, NurseStudy.Net. Available at:
https://nursestudy.net/leukemia-nursing-diagnosis/ (Accessed: November 9, 2022).
● Marianne Belleza, R.N. (2021) Acute lymphocytic leukemia nursing care management: Study guide ,
Nurseslabs. Available at:
https://nurseslabs.com/acute-lymphocytic-leukemia/#:~:text=Nursing%20Management,provide%20teachi
ng%20and%20psychological%20support. (Accessed: November 9, 2022).
● Matt Vera, B.S.N. (2022) 5 leukemia nursing care plans, Nurseslabs. Available at:
https://nurseslabs.com/5-leukemia-nursing-care-plans/ (Accessed: November 9, 2022).
● Nursing guidelines, children & beta thalassemia - researchgate.net (no date). Available at:
https://www.researchgate.net/profile/Sahar-Abd-Elgawad/publication/352226972_Nursing_Guidelines_for_
Children_Suffering_from_Beta_Thalassemia/links/60c001a892851cecf165921a/Nursing-Guidelines-for-Chil
dren-Suffering-from-Beta-Thalassemia.pdf (Accessed: November 9, 2022).
● Marianne Belleza, R. N. (2021, February 11). Thalassemia nursing care planning and management study
guide. Nurseslabs. Retrieved November 10, 2022, from https://nurseslabs.com/thalassemia/ (Accessed:
November 7, 2022)
● Leifer, G. (2018). Introduction to maternity and pediatric nursing (8th ed.). Saunders. (Accessed: November 7,
2022)

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