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Acute Lymphoblastic Leukemia (ALL) – Eight Points to Remember

Here we are. Safe-and-sound doing our day-to-days; work, home, dinner, sleep, and up the next morning to do it all over again. Work is okay. School is okay. And, life is okay. We worry about this and that. We contemplate debt, mortgages, jobs, friends, family and what’s for dinner. Our Facebook feed parallels a life that, for the most part, is the essence of the “Kodak Moment.” Life is good. But, for a family with a child who has just been diagnosed with cancer, there’s not a thing in the world that matters other than this one, now defining, moment. Everything that seemingly was so important two seconds ago is now an afterthought and matters less than a pebble somewhere on the surface of Mars. People hear “Cancer” ( Acute Lymphoblastic Leukemia ) and think “the end.” 

In walks the AWESOME school nurse. And though none of this is “about” the school nurse; the school nurse will play a pivotal point in the care of this child and the family. Let me explain:

As an old hospice nurse, I would think of myself as the director of a play. The social worker, chaplain, CNA, and even the doctor were all actors in my play with the star being the patient and the audience being the family. The “play” wasn’t always a tragedy either. This was evident at the funeral when the family and friends would speak about who they loved so much. Many times the genre’ of the “play” was known by the eulogies. There were definitely the tragedies. But more often were the dramas, the actions, the adventures and even the comedies. The hospice nurse…the case manager…had all the answers and knew how to direct the play and put everyone at ease (as “at ease” as possible given any of the unique situations). One family member told me once, “You just walked in that first day and took over. That was the day we went back to being our mother’s daughters.” 

Families feel a loss of control when they here “cancer.” And even after a few months of regaining some sense of emotional control as the child improves. They will lose a bit of that comfort when the day for their child to go back to school arrives. They need a “director” who they feel confident in and in whom they can honestly say, “My child is safe and sound at school because my school has an AWESOME school nurse.” They want to feel you have all the answers and solutions to every problem. And knowledge builds confidence. So, let’s learn a bunch about Acute lymphoblastic leukemia (ALL) – the most common type of cancer in children.

Here are a few videos that may interest you (they did me).

T-cells and B-cells – The Special Ops of the Immune System.

When Bacteria, Viruses, Cellular Debris, Foreign Substances and Parasites, also known by Nurse Kevin as “cooties,” enters the body, the first line of defense rushes in and starts “munching up” the invaders. These “munchers” are called Macrophages and are a type of white blood cell of our immune system that actually engulfs…eats…and digests these “cooties.” 

Then there are the T-Cell and B-Cell white blood cells. These cool dudes actually organize a strategy of defense that uses past infections to “learn” to identify specific threats and attack them when they try to invade the body again.

There are these two types of white blood cells: innate and acquired cells. The innate cells are the muscle (figuratively speaking) of the immune system. They attack the invaders as they see them enter the body first. These macrophages are quick to attack and kill every cell they can that isn’t one of our cells. The acquired cells are your “smart” white blood cells that the “cooties” may “fool” at first (first exposure) but if these “smart” white blood cells ever find that same “cootie” back in the body, it’s these T-Cells and B-Cells that jump into action. This is how our vaccines work to protect us from things like Polio and Chickenpox.

There are 10 billion different B-cells. They are so tiny that you’ll never be able to see them without magnification, but if you lined them all up, they would stretch out 100 soccer fields. We need…I mean NEED these B-Cells to be there for us in this dirty world. There are cooties EVERYWHERE. That breath you just took in…thousands on thousands of cooties. That finger that kinder (or senior) just stuck in their nose…cooties. 

In Acute Lymphoblastic Leukemia (ALL), especially in children, the numbers of B-Cells is dramatically affected. Though ALL could affect both B-Cells and T-Cells, in children, you’ll find that ALL is usually having an impact on the child’s B-Cells. 

B-Cells are made in the marrow and then travel to the spleen and lymphoid tissues where they become “immunocompetent B cells.” In other words, they are all grown up, have finished basic training and are ready for battle. What happens in ALL is abnormal cells are growing VERY fast in the bone marrow, where B-Cells are made and “crowds out” the B-Cells. Fewer immunocompetent B-Cells equals a higher risk of infection. After all, a bigger invading army of cooties can overcome the futile attack of a smaller defensive army of B-Cells.

Whew. That’s was a mouth-full…and Nurse Kevin is still typing…

The normal range for the white blood cell count varies and is usually between 4,300/µL and 10,800 /µL of blood. In ALL, you will find levels up and above 65,000/µL. You may even see lab values may be higher than 100,000/µL.

It’s likely that a child will have received this diagnosis and be out of school for the induction chemotherapy and probably will be working with a hospital staff member or contracted staff member who will work as the child’s teacher while therapies are carried out as an inpatient. He or she will receive medications like Vincristine, a chemotherapy drug works to stop cancer cells from multiplying and Daunorubicin that slows or stops the growth of cancer cells in the body

There are Three Phases of Treatment


Kill the leukemia cells in the blood and bone marrow and put the disease into remission (a return to normal blood cell counts)


To rid the body of any remaining cells that could begin to grow and cause the leukemia to return (relapse)


To destroy any cancer cells that might have survived the first two phases

Four types of treatment may be used during any of these treatment phases:

Chemotherapy – Powerful medications that kill cancer cells or stop them from growing and dividing.

Stem cell transplant – Includes replacing blood-forming cells in the bone marrow that have been killed by chemo and/or radiation therapy

Radiation therapy – Uses high-energy X-rays or other types of radiation to kill cancer cells or stop them from growing.

Targeted therapy – Uses medicines or other treatments that target and attack specific cancer cells without harming normal cells.

As the school nurse, you will not likely see the child during this induction chemotherapy period. However, you may see the child later in the treatment phases and yes, you’ll see the hair loss and occasional nausea symptoms and vomiting (Ondansetron will likely be a PRN drug you’ll offer this child when symptoms present).

Back To School – Eight Points To Remember

The care you provide these children in the school setting will be supportive. You may administer appetite promoting drugs and anti nausea drugs. And you will promote education in the classroom to the children as well as the teachers and support staff that comes into contact with the child.

Point One

I have found that by the time the child has returned to school, the parents and the child have gone through much of the emotional challenges that this diagnosis brings. They have emotionally traveled from one day being a “normal” child where they enjoyed school, making friends, fighting with siblings (this doesn’t change) and just doing the day-to-day of growing up to now enduring a prolonged hospital stay(s), needles being stuck in their bodies, tests being performed, taking a ton of new pills, and all the side effects of these pills and treatments.

Point Two

They will (usually) have a device called an implantable port or port-a-cath under the skin on the chest on the child’s non-dominant side. You will rarely (if ever) have to access this in the school setting. But, you will need to know all the information about this port incase there’s ever an emergency and EMTs arrive. Knowing this information will help them care for the child.

Point Three

There’s going to be a cancer care team that will have been working with the child and his or her parents. These are your go-to folks. They will have been with this child through the thick-and-thin for the majority of time the child has been receiving therapies. They not only know ALL (inside and out) they know how this child specifically responds to ALL and the unique methods by which the child has coped with this diagnosis up and to the point of the consideration to return to school.

Consider obtaining permission from the parents AND the child to have this cancer care team come to the school and speak to the class about their returning classmate. This team has the experience to answer most any question that may pop up during this discussion. Trust me; you’ll learn something too.

Point Four

You will need to prepare and plan for a 504 plan or Individualized Education Plan (IEP). He / She WILL miss days of school. This is a given. The child may only be able to tolerate half-days of school. We’ll talk more about care plans soon.

You’ll need to plan for any special accommodation needs such as wheelchairs, walkers, help with certain physical activities, and needs for special devices.

Point Five

Don’t expect everything to go as planned. I have had children return to school and jump right in where they left off. In one case, I had a child return and all his buddies said, “He’s still Frank, just a bald-headed Frank.” (“Frank” – not the real name). This didn’t go as planned because the only change was the medications he needed to take at school. Not as planned but I had planned for the worse…so this was a GOOD THING.

I have also had children that spend 75% of their day in the nursing office sleeping or just “hanging out.” This didn’t go as planned because they spent most of their day outside of the classroom instruction. They ain’t gonna learn much outside of the classroom. An accommodation was in order.

Point Six

The child may need two sets of books. I remember when I was in school we were assigned text books and we carried them back and forth to school and home. Now, a lot of the books are just kept at the school for the children to use at the school. Our little ALL children may need a set of these books at home to either avoid having to carry heavy books with their exhausted bodies or have a set at home to use incase of an unexpected (yet expected) absence.

Point Seven

Pills. Loss of Appetite. Dry Mouth. Chemotherapies. Messed Up Schedules. Waiting Rooms. All of this will mess with a child’s “normal” including the child’s normal voiding and elimination patterns. Plan for the child to need to Poop and Pee anytime they need to and “exit” the classroom as discreetly as possible. Just sayin’.

Point Eight

Find a new normal. Truth be known: There will be a need for a new normal and finding a new normal will be challenging. Unfortunately, there is no “going back.” The child and the family will never find that pre-cancer normal ever again. Seems harsh to say? Not really. There’s a new normal for a lot of things that may be considered good or bad (subjectively speaking).

Good News

According to St. Judes, 98% of children with ALL go into remission within weeks after starting treatment and about 90% of those children can be cured. (10 years in remission). Remember that “new normal” we talked about in Point Eight? Sure you do! The child and his / her family will likely find that “new normal”…whatever that may end up looking like…they will find it. And, statistically speaking, they will find that new normal to be A-OK and be happy to find that new normal…together.

Acute Lymphoblastic Leukemia (ALL) Plan of Care

I have created a very generic plan of care for ALL…and Leukemia in general. It’s free to download (no strings attached). All I want from you is your input; what should we leave out of this plan of care and what should we put in this plan? It’s OUR plan of care…us School Nurses. Click the IV to download the PDF.

I hope you enjoyed this article. There’s more coming. Want to make sure you get the latest from your ol’ buddy Nurse Kevin? Sign up for the Go See The Nurse Newsletter (I won’t bug you; I promise).

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Nurse Kevin
Nurse Kevin is a school nurse who takes care of school children in Southwestern Idaho. Nurse Kevin authors content for many different websites including,,,,,

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3 thoughts on “Acute Lymphoblastic Leukemia (ALL) – Eight Points to Remember

  1. I really enjoy everyone of your articles. I am wondering if you would be willing to share your IHP template. It is the best one I have seen. I am in a small rural Texas school district with 4 schools. Each campus has their own nurse, but we don’t have a senior/district nurse. I have multiple IHP’s in my files and would like to standardize everything. That is my goal this year!!!! If you would share, I would be very appreciative. If not, thanks anyway. Keep the articles coming!!!!!! If you are ever in Central Texas, stop by Llano Elementary and I will treat you to the best BBQ you will ever eat!!!!! Marrijane

    1. Hello Nurse Marrijane! Send me a “Comment” from the comments tab at the very top of this page. I will be happy to share. I use a program from Adobe called InDesign.

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