Nursing diagnoses in patients with leukemia

Nursing diagnoses in patients with leukemia

Courtens, A M

PURPOSE. To identify and describe nursing diagnoses, their related factors, and defining characteristics, in hospitalized leukemia patients and to categorize these nursing diagnoses within Functional Health Patterns.

METHODS. Content analysis of 15 nursing records and interviews with 7 oncology nurses working on a hematology/oncology ward in a University hospital in Maastricht, the Netherlands.

FINDINGS. In the leukemia population, 47 nursing diagnoses with their associated characteristics were identified and classified within 10 Functional Health Patterns. Most of the nursing diagnoses were related to the NutritionalMetabolic, the Cognitive-Perceptual, ActivityExercise, the Role-Relationship, and the CopingStress-Tolerance patterns.

CONCLUSIONS. Results describe the nursing care needs of patients with leukemia. Since the study used a small sample, results should be interpreted with caution. Further research is recommended.

Key words: Leukemia, functional health patterns, nursing diagnosis

The recognition of cancer as a major health problem has led to the development of oncology nursing as a specialty. The practice of the oncology nurse extends to all care settings in which individuals with an actual or potential diagnosis of cancer receive health care, screening, or patient education. The complexity of care for cancer patients is high because a variety of physical symptoms, functional limitations, psychosocial disruptions, and knowledge deficits may occur in these patients.

Oncology patients quite often share the same common nursing care needs. The oncology nurse is responsible for identifying these needs, making appropriate diagnoses, and initiating care plans. Nursing diagnoses may provide a common vocabulary for communication that enables nurses to summarize the conclusions of their assessment in clear and concise statements. A classification system for nursing diagnoses may be helpful to define the body of knowledge for which oncology nurses are accountable and to emphasize the focus of oncology nursing.

From the viewpoint of care delivery, nursing diagnoses may establish a system that is suitable for computerization and provide the opportunity to develop a computerized healthcare system that would collect, analyze, and synthesize nursing data for practice and research (Carpenito, 1993).

In oncology nursing there is a growing interest in the incorporation of well-developed nursing diagnoses that can assure comprehensive, individualized care for patients. In the Netherlands, the concept of nursing diagnosis recently has become a topic of major importance. Although a “working definition” of nursing diagnosis was developed, and research is being carried out to develop a framework for nursing diagnoses (National Council for Public Health, 1993), no list of accepted and classified diagnoses exists. One of the results of a pilot study of the National Council for Public Health is agreement on the usefulness of the Functional Health Patterns proposed by Gordon (1994). The relative ease with which nurses can understand this framework and apply it in a variety of settings has prompted its acceptance as a valuable guide for assessment.

A framework for nursing diagnoses can be developed using a combination of inductive and deductive methods. One of the first steps in research of nursing diagnoses in the Netherlands may be the identification of responses to actual or potential health problems, their characteristics, and etiology in certain patient groups. In a university hospital in Maastricht a study was conducted to identify nursing diagnoses in leukemia, lung cancer, and colon cancer patients and to cluster them in Gordon’s functional health patterns.

In this article only the study with the medical diagnosis leukemia will be reported. Research questions were:

1. What is the nature of nursing diagnoses in admitted leukemia patients, and which nursing diagnoses are frequently encountered?

2. What are the characteristics and etiological factors mentioned by nurses and documented in nursing records?

3. Which nursing diagnoses are reported by nurses to be “difficult”?

4. In which Functional Health Patterns can the diagnoses be categorized?

Literature Review

The term leukemia includes abnormalities of proliferation and maturation in lymphocyte and myeloid cell lines. It is the name given to a group of hematologic malignancies affecting bone marrow and lymph tissue. The number of new cases of leukemia in the Netherlands (15.5 million inhabitants) is approximately 660 in men and 516 in women, with mortality figures of 601 in men and 487 in women (Netherlands Cancer Registry, 1997). Leukemias can be classified as either chronic or acute and as either myeloid or lymphoid. The chronic leukemias have an excessive accumulation of matureappearing but ineffective cells and have a slow progressive course (2-5 years). The acute leukemias are marked by an abnormal proliferation of immature blood cells with abrupt onset and rapid disease progression that results in short survival time. The type of leukemia, lymphocytic or myelogenous, is named according to the point at which cell maturation is arrested.

Manifestations of leukemia are related to excessive proliferation of immature leukocytes within blood-forming organs, infiltration of proliferating leukocytes into various organs in the body, and decrease in the number of normal blood cells. Most of the individuals with leukemia undergo intensive chemotherapy. The effect of this cytotoxic therapy is hypoplasia, which puts patients at risk for infection, bleeding, and anemia.

One of the side effects of chemotherapy is neutropenia, which can be defined as an absolute neutrophil count less than 1,000/mm3. Approximately 60% of neutropenic patients develop infections, which is the major complication for leukemia patients (Wujcik, 1993). Most infections are due to organisms endogenous to the host or present in the environment. The most common sites of infection are the alimentary tract, sinuses, lungs, and skin (Haagedoorn & Bender, 1992; Scheffer & Wade, 1987). To prevent infection, treatment in a private room may be necessary and visitors restricted. In certain circumstances, such as bone marrow transplants, isolation may be used (Wujcik).

Anemia, another side effect caused by hypoplasia, may cause patients to feel out of breath, dizzy, weak, and tired (Ambaum, 1994; Camp-Sorell, 1993; Knobf & Durivage, 1993).

Thrombocytopenia is another well-known side effect, which can be defined as the abnormal decrease in the number of circulating platelets. The potential for bleeding occurs when platelet levels fall below 50,000/mm3. The first evidence of bleeding may be petechiae or ecchymoses on the skin or mucous membranes or oozing from gums or nose (Wujcik, 1993).

Oral complications often occur in this patient group and may be the result of the disease or therapy. The direct toxicity of chemotherapeutic agents, in combination with prolonged neutropenia, renders the patient at high risk for oral infection (Nieweg, 1995; Uitterhoeve, 1994).

Individuals with leukemia and their significant others may be, like all patients with malignancy, at risk for inetfective coping, fear, anxiety, or hopelessness (Bertero, 1996). Emotional ups and downs related to multiple remission inductions and relapses might be exhausting to patients and families.

No specific study was found in the literature addressing nursing diagnoses in leukemia patients. Some studies focus on the identification of nursing diagnoses in other oncology populations, but as oncology patients often share the same problems, an overview of these studies might be helpful.

Mundinger (1978) was one of the first to emphasize the importance of nursing diagnoses. Problems like nausea, despair, and withdrawal were identified as important problems in oncology patients. Fredette and Gloriant (1981) identified 35 specific nursing diagnoses for patients receiving chemotherapy. They used the NANDA list of diagnoses with expansion of some diagnoses like nausea and vomiting. Herberth and Gosnell (1987) conducted an analysis of 224 articles published between 1981 and 1984 to determine the status and use of nursing diagnoses in oncology nursing practice. A majority of the articles (n = 140) focused on nursing diagnoses; 29% (n = 41) focused on psychosocial problems, with the majority of those relating to the Coping-Stress Tolerance functional health pattern. Sixteen percent of the articles dealt with problems in the NutritionalMetabolic pattern, with half of these about nausea and vomiting. The most frequently occurring specific diagnosis was knowledge deficit, often in combination with the theme self-care (Herberth & Gosnell).

Bramwell (1989) surveyed 566 nurses in a study designed to identify what problems are seen as “difficult” in the care of cancer patients. Difficult was defined as “the wish to have a better solution for the problem.” Coping problems with diagnoses and disease course-as well as anxiety, anger, and denial-were identified as difficult problems. In the category of physical problems, maintaining adequate nutrition and pain were identified as difficult. In a qualitative analysis in this study, 1,052 statements of nurses were analyzed. Most of these statements included ineffective coping, pain, altered nutrition, nausea, constipation, and fatigue.

Antall (1989) analyzed the nursing records of 14 cancer patients at time of discharge. Activity intolerance, sleep disturbance, altered nutrition, constipation, and pain were found in half of the patient group. Miaskowski and Garofallou (1986) also analyzed records of 282 oncology patients. Pain (n = 92) and anxiety (n = 69) were the diagnoses that occurred most frequently.

In 1991, Woodtli and Van Ort published a study on nursing diagnoses in patients with head and neck cancer who were treated with radiotherapy. The purpose of the study was to identify and describe nursing diagnoses and categorize nursing diagnoses within Functional Health Patterns. Eighteen nursing diagnoses were identified within eight Functional Health Patterns. Most of the nursing diagnoses were related to the NutritionalMetabolic and the Activity-Exercise patterns. The same authors conducted a descriptive study to identify and describe core and site-specific symptoms of 15 patients with cancer of the digestive organs who received external radiotherapy. Seventeen diagnoses with their associated defining characteristics were classified within eight Functional Health Patterns. Half of the diagnoses were formulated within the Nutritional-Metabolic and Elimination pattern (Woodtli & van Ort,1993).

MacAvoy and Moritz (1992) conducted an identification and validation study on nursing diagnoses, signs and symptoms, and related factors. In the records of 48 cancer patients, 52 diagnoses could be identified. Altered nutrition (n = 44), pain (n = 26), ineffective individual coping (n = 15), sleep disturbance (n = 11), impaired skin integrity (n = 9), and self-care deficit (n = 8) often were identified.

From these studies it seems that Nutritional, ActivityExercise, and Coping-Stress Tolerance patterns are highly affected by cancer. Nursing diagnoses such as altered nutrition, pain, ineffective coping, anxiety, self-care deficit, activity intolerance, and sleep disturbance frequently occur in general oncology populations and also might occur in leukemia patients. Based on knowledge about the disease and the treatment, patients with leukemia might be at risk for the nursing diagnoses risk for infection and risk for bleeding and for nursing diagnoses that often occur in patients with severe chemotherapy (e.g., altered oral mucous membrane, nausea, fatigue, altered body image). This study was done to confirm these expectations and investigate how the nursing diagnoses, their characteristics, and etiological factors of this patient group are described in patient records and by nurses themselves.


A descriptive design was used to identify and categorize diagnoses within the Functional Health Patterns. Two different methods, content analysis of patient records and interviews with experienced nurses, were used to gather information in this study.

Content Analysis of Records

Sample. A convenience sample of 15 nursing records of patients with leukemia was analyzed from admission until discharge. The sample was composed of 15 adult patients with the medical diagnosis acute myeloid leukemia (n = 9), acute lymphatic leukemia (n = 5), and chronic myeloid leukemia (n = 1). The patient group consisted of 11 women and 4 men. The mean age of the sample was 49 years, range 24 to 69 years. Patients were admitted for several reasons: treatment with chemotherapy, bone marrow transplantation, general malaise, thrombopenia, and anemia. The average period of hospitalization was 6 weeks.

Procedure. Text fragments concerning nursing diagnoses (sign and symptoms, related factors, problem descriptions) in the records were coded and described. The NANDA diagnoses and the Functional Health Patterns of Gordon were used as a checklist. In order to provide interrater reliability, three of these records were chosen randomly and evaluated by a clinical nurse specialist in oncology nursing. The degree of agreement about the labels in the records was calculated by means of the formula of Holsti (1969). Interrater reliability coefficients were sufficient and ranged from 65% to 90%.

Interviews With Nurses

Sample. Seven registered oncology nurses, two men and five women, who worked on the oncology/hematology ward were interviewed by the researcher by means of a semistructured interview list. They had an average experience of 4 years with oncology patients.

Procedure. The nurses were interviewed in their ward by the researcher. Topics in these interviews included what kind of problems they identified in leukemia patients, how are these problems characterized, and what are the most difficult problems to deal with. To improve reliability of data, interviews were tape recorded and transcribed. Text fragments concerning nursing diagnoses (characteristics, related factors, labels, problem descriptions) were coded and described. The interviews also were judged by a second investigator (an expert in oncology nursing and nursing diagnoses) to establish interrater reliability. The expert also coded the records by means of the diagnoses list, and the degree of agreement between the researcher and the second investigator about the labels was calculated. Reliability coefficients varied from .78 to .90, which is considered sufficient. Results of the analysis of records and interviews were discussed with several oncology nurses and compared to the literature.


Nursing Diagnoses and Characteristics Identified From Nursing Records

In the 15 nursing records of leukemia patients, 36 different diagnoses were identified (Table 1). As expected, most of them were classified in the Nutritional-Metabolic pattern (n = 9), Activity-Exercise pattern (n = 6), and Cognitive-Perceptual pattern (n = 6). The number of diagnoses varied from 1 to 24 per record. The mean number of diagnoses was 16 per record; the mean number of different Functional Health Patterns was 7.

The diagnoses that occurred mostly were sleep disturbance, risk for bleeding, fluid volume excess, skin problems, fatigue, pain, altered nutrition: less than body requirements, nausea, altered oral mucous membrane, risk for infection, diarrhea, and self-care deficit related to hygienic care. Each of these diagnoses was found in at least 10 of the 15 records. Most of the nursing diagnoses are accepted NANDA diagnoses, except pruritus, nausea, vomiting, tingling, and dizziness. These patient problems were added to the list. Interestingly, in the nursing records, mostly physical problems were documented. It was remarkable also that most of the records consisted just of reports on combinations of defining characteristics of nursing diagnoses. Concise formulated nursing diagnoses-including a problem, etiological factors, and sign and symptoms-were hardly found. Patient outcomes and evaluations of nursing interventions were not found in the records.

From the diagnoses that occurred frequently, a list was made of the characteristics found in the records (Table 2). Most of these characteristics were also documented in the NANDA list of diagnoses.

Nursing Diagnoses and Characteristics Identified From the Interviews

From the interviews with the 7 experienced nurses, 36 nursing diagnoses could be identified. Most of the diagnoses also were found in the records, but 11 nursing diagnoses that were mentioned in the interviews were not found in the records. Most of these additional diagnoses, except altered tissue perfusion, were psychosocial problems such as changes in sexuality and intimacy, impaired adjustment, anticipatory nausea, decisional conflict, denial, change in family role, change in parenting, knowledge deficit (family), and uncertainty. Nurses did not write these problems in the patient records. These nurses also mentioned additional defining characteristics.

Most of the nursing diagnoses identified in the interviews could be classified in the Nutritional-Metabolic (n = 9), Cognitive-Perceptual (n = 7), Activity-Exercise (n = 4), Coping-Stress Tolerance (n = 4), and the Role-Relationship patterns (n = 4).

The interviews were coded by a second investigator. The problems and characteristics and sometimes etiological factors were easier to interpret than the problems in the records. The two investigators agreed on all diagnoses. Table 3 categorizes the labels, characteristics, and related factors mentioned in the interviews according to the Functional Health Patterns.

Difficult Problems Identified by Nurses in the Interviews

When the nurses were asked what kind of problems they experienced as difficult to treat, two categories of answers could be distinguished: nursing diagnoses or patient-related problems, and problems felt by nurses related to interventions for the patients.

In the first category, the nurses mentioned uncertainty, denial, communication between patients and families, sexual problems, ineffective coping, and adjustment. These psychosocial problems are sometimes hard to deal with. Nurses found it difficult to find a solution for them: [F]uture, uncertainty, it is all open questions.

Patients and family keep on asking, they want to have answers but we don’t have an answer, we only have hope….

In the second category, ethical dilemmas were emphasized, for example:

We often go on with treatment, while the chance of recovery or improvement is very small. Patients who are in remission become very ill because of the treatment.

The nurses perceived four problems with interventions. The first problem was motivating patients to take their medicine or stimulating patients to go on with the treatment while they know it hurts or will increase pain.

It’s hard to tell a patient with a very painful throat, who is not able to swallow, that he should take his medications, sometimes six different drugs in an hour.

Another problem mentioned by these nurses was the inability to speak fairly with patients because the nurse does not want to take away the hope of patients and families. Patients with leukemia, mostly young people, often stay very long on the ward or are readmitted several times. Nurses often have a close and confidential relationship with these patients. The emotional burden for these nurses is high.

Some patients are admitted several times for long periods. With most of them we have a close relationship. For me it is an issue, how close can I go in my relationship with a patient? We enter into the life of the patient, are disappointed when blood counts stay low, or are jubilant when someone gets out of isolation. Sometimes I think it is also different because of the fact that some of our patients are very young, it is very hard to see that the future of a young person is destroyed….

Caring for relatives or family is another difficult problem. Nurses experience a shortcoming in helping these people when the patient has died.

Communicating sexual problems or infertility also are problems the nurses identified as difficult. For patients and nurses it is not an easy subject to discuss; it is still seen as a taboo.

Discontinuity of care is an organizational problem that is seen as hard to solve by nurses. They are not able to follow the patient after discharge. Sometimes patients come back to the ward just to ask some questions or speak with the nurses about the admission time. Nurses feel there is a lack of aftercare when the patient is at home.


An extensive list of human responses to leukemia were encountered in this population (47 different nursing diagnoses). The nursing care of leukemia patients is very complex, and many different Functional Health Patterns are affected by this disease.

The findings, considering “high frequency diagnoses” (found in at least 66% of the patient records), confirm the results of some other studies. Sleep disturbance, impaired skin integrity, pain, altered nutrition, nausea, and self-care deficit also have been reported as “high-frequency diagnoses” in other studies (Antall, 1989; Bramwell, 1989; Herberth & Gosnell, 1987; MacAvoy & Moritz, 1992). Risk for bleeding and risk for infection are, more than the other diagnoses, typical with leukemia patients. The combination of immature or decreased blood cells and severe chemotherapy treatment can cause these risks. Fluid volume excess, fatigue, diarrhea, altered nutrition, nausea, and impaired skin integrity were expected to occur in patients with severe chemotherapy. Most of the diagnoses mentioned above are in a certain degree predictable in this patient group. A large number of patients probably will have these problems, and nurses should be educated and prepared to treat them.

Out of the interviews, 36 nursing diagnosis could be identified and classified, of which 25 also were identified in the patient records. The nurses emphasized psychosocial problems in the interviews. These psychosocial diagnoses were seen by nurses as difficult to treat, which may explain the lack of attention given to these diagnoses in the records.

Nursing diagnoses that were experienced as difficult (hard to find a solution) to treat were mostly problems considering the Coping-Stress Tolerance pattern and Role-Relation pattern: uncertainty, denial, ineffective coping, and adjustment, sexual problems, and communication problems between patients and family. These findings confirm the results of Bramwell (1989), who reported that nurses defined coping problems and denial as “difficult.” Other problems (not nursing diagnoses) that were considered difficult were ethical dilemmas, motivating patients, inability to be fair with patients, speaking about sexuality, and discontinuity of care.

Most of the nursing diagnoses could be classified in the Nutritional-Metabolic, Activity-Exercise, RoleRelationship, Coping-Stress Tolerance, and CognitivePerceptual patterns. These findings confirm the results of other researchers (Woodtli & Ort, 1991), signifying the importance of these patterns in cancer nursing.

Each of the two methods used to gather information generated additional and relevant information. In the records, nurses mostly wrote just characteristics. Labels, related factors, outcomes, and evaluations were hardly found. This result confirms the findings of Ehnfors and Smedby (1993), who found that two thirds of the records had no nursing care plan and 90% had no nursing diagnosis. One can conclude that the studying of patient records is not enough to gain information about the content of nursing diagnosis. Additional methods such as patient interviews and observations on oncology wards might be useful in this case.

In this study, NANDA diagnoses were used. These diagnoses are accepted but not validated. Some diagnoses were found that are not included in the NANDA taxonomy. There may be a need to develop these new diagnoses and to refine the current diagnosis. Some of the characteristics also were different from the NANDA characteristics. The table of diagnoses, etiological factors, and characteristics need to be completed and validated by experts and further clinical validation.

The results of this study give some insight into the nursing diagnoses and care needs that may occur in leukemia patients. These nursing diagnosis might form a beginning framework for development of research-based assessment guidelines and care plans for this specific patient population. For each of the high-frequency diagnoses, a care plan (including outcomes and interventions) can be made. The complete list could be used as a checklist in the patient record to help nurses to use the nursing process in a proper way.

The use of nursing diagnoses and these care plans might be appropriate for and might enhance oncology nursing practice. Guidelines and care plans are especially necessary for the problems that are considered by nurses as difficult to treat. The results of this study might be the starting point for discussion on the ward about how to deal with these problems. Structural intervention or supervision groups might be helpful in supporting the nurses and finding solutions for these problems.

A patient’s record should represent a total overview of a patient’s diagnoses, outcomes, interventions, and evaluation. Yet in the records, mostly physical problems were identified. Nurses can be encouraged to record the psychosocial diagnoses that were identified in the interviews.

Insight into the occurrence of nursing diagnoses can be relevant for management purposes. Computerized data sets of nursing diagnoses can be used for planning personnel and materials and used in calculations of costs of nursing care at oncology wards.


Since only 15 patient records were studied and seven nurses were interviewed, the results of the study should be interpreted with caution. Further research in other hospitals and outpatient settings with a larger sample is recommended.


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A.M. Courtens, PhD, RN, is Assistant Professor, and H. Huijer Abu-Saad, PhD, RN, is Professor, Department of Nursing Science, University of Maastricht, Maastricht, The Netherlands.

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