Primary Nursing Diagnosis

Risk for infection related to decreased primary and secondary responses

OUTCOMES. Immune status; Knowledge: Infection control; Risk control; Risk detection; Nutrition status; Treatment behavior: Illness or injury; Hydration; Knowledge: Infection control

INTERVENTIONS. Infection control; Infection protection; Surveillance; Fluid/electrolyte management; Medication management; Temperature regulation

570 Leukemia, Chronic

^ PLANNING AND IMPLEMENTATION Collaborative

In CLL, because treatments destroy normal cells along with malignant ones, therapy focuses on the prevention and resolution of complications from induced pancytopenia (anemia, bleeding, and infection in particular). When diagnosed, most patients do not require chemotherapy unless they have weight loss of more than 10%, extreme fatigue, fever related to leukemia, or night sweats. Other signs that warrant chemotherapy are progressive bone marrow failure, anemia or thrombo-cytopenia that does not respond to corticosteroid treatment, or progressive splenomegaly, lym-phadenopathy, or lymphocytosis (>50% in 2 months or doubling of count in less than 6 months). Chemotherapy is therefore employed to reduce symptoms.

Total body irradiation or local radiation to the spleen may also be given as a palliative treatment to reduce complications. Two complications during later stages of CLL are hemolytic anemia (caused by autiommune disorder) and hypogammaglobulinemia, which further increases the patient's susceptibility to infection. Antibiotics, transfusions of red blood cells, and injections of gamma globulin concentrates may be required for patients with these problems.

Therapy in the chronic phase of CML focuses on: (1) achieving hematologic remission (normal complete blood cell [CBC] count and physical examination without organomegaly); (2) achieving cytogenetic remission (normal chromosomes); (3) achieving molecular remission (negative polymerase chain reaction [PCR] result for mutated RNA). Leukapheresis (separation of leukocytes from blood and then returning remaining blood to patient) may be performed to lower an extremely high peripheral leukocyte count quickly and to prevent acute tumor lysis syndrome, but the results are temporary. Platelet pheresis (separation of platelets from blood and then returning remaining blood to patient) may be required for thrombocytosis as high as 2 million. Apheresis (separating blood into components) is usually performed with the use of automated blood cell separators that are designed to remove the selected blood element and return the remaining cells and plasma to the patient.

Allogeneic (belonging to same species) bone marrow transplantations before blast crisis offer the best treatment option. Chemotherapy is used in treating CML, but at this time, it has not proven satisfactory in producing long-term remission. Supportive care and management of complications from chemotherapy are handled pharmacologically with antibiotics, antifungals, and antiviral drugs. Some patients also need transfusions with blood component therapy to control infection and prevent bleeding and anemia. To relieve the pain of splenomegaly, irradiation or removal may be used.

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