Case Study on LEUKEMIA

I.

Introduction

I personally selected this case of Acute Myelogenous Leukemia (AML) to enhance my knowledge concerning its clinical manifestations, possible causes, cure and prevention, among others. This knowledge will eventually become an indispensable tool that can be shared to others and will never go out of style. It is a privilege to embrace this challenge in the form of service to humanity and the fulfillment of our nursing profession. Our core competence is the bare essential towards its success. As a nursin nursing g profes professio sion, n, it is impera imperativ tivee to learn learn new techni techniques ques in modern science in order to develop skills that would benefit the medical world. This learning potential must be relayed to posterity and develop new techniques, state -of –the- art technology that caters the modern man. In the final analysis, the achievement of one’s endeavor may usher us to find the light we are seeking for. First of all what is leukemia? Leukemia is a cancer of the blood, and is characterized by uncontrolled proliferation and accumulation of leukocytes (white   blood blood cells) cells).. Most Most leukem leukemic ic cells cells never never mature mature into into functi functioni oning ng leukocy leukocytes tes.. Where in the body is deprived of vital components of its immune system. Also, the cells accumulate in the blood and in certain organs, forcing out healthy cells and interfering with the function of that organ. There many different types of  leukemia but the four most important forms are derived from only two types of  cells, lymphocytes and myelocytes. Acute myelogenous leukemia is disorders of 

granulocytes. Granulocytes produced by bone marrow, engulf and digest bacteria and other small particles. This generally appears suddenly with symptoms like those of cold, and progresses rapidly. The lymph nodes, spleen and liver may   become become infilt infiltrat rated ed with with leukocy leukocytes tes and enlar enlarged. ged. There is often often bone pain, pain,  paleness due to anemia, a tendency to bleed easily because of depleted platelets and high susceptibility to infections. The most common causes of death, which occurs on the average within three months if without treatment, are hemorrhaging and uncontr uncontroll olled ed infect infection ions. s. Acute Acute myelog myelogenou enouss leukemi leukemiaa occurs occurs much much less less frequently in children.

II. Objectives

General Objectives: After 3 days of giving holistic care, the patient will be able to regain optimum level of functioning and adopt coping skills in performing activities of daily living. Specific Objectives: After 8 hours of giving holistic nursing care, the patient will be able to: 1. establi establish sh rappor rapportt with with the stud student ent nurse nurse 2. explain explain reason reasonss of hospit hospitali alizat zation ion 3. state past medical medical history history related related to present present conditi condition on 4. identify identify the precipitat precipitating ing and predisposing predisposing factors factors that that can possibly possibly lead to the occurrence occurrence of the condition 5. discuss discuss the management management applied applied upon the the occurrence occurrence of the disease disease After 8 hours of giving holistic care, the student nurse will be able to: 1. establ establish ish rappor rapportt with with the the patie patient nt 2. presen presentt the patie patient’ nt’ss person personal al histor history y 3. assess assess the the patient’ patient’ss level level of growth and developme development nt 4. show present present profile profile of functio functional nal health patterns patterns

5. discuss discuss with with the patient patient the diffe different rent predispos predisposing ing and precipita precipitating ting factors factors 6. identi identify fy the patho pathophy physio siology logy and and ration rationale ale 7. construct construct a compreh comprehensive ensive nursi nursing ng care plan plan appropriat appropriatee for the the patient patient 8. discuss discuss different different measures measures for home management management

PHYSICAL ASSESSMENT

Body Parts

Inspection

Palpation

HEAD

Round in shape  Normocepahlic

 No tenderness  No Lumps

HAIR 

Evenly distributed, Black in color, short, straight hair, smooth

SCALP

 No dandruff 

FACE

Presence of   pimples noted,  No wrinkles,  brown in color 

FOREHEAD

Round, brown in color, No wrinkles,  pimples noted

 No Lumps noted

EYEBROWS

Black in color, no lesions noted

 No Lumps noted

EYELIDS

Closes and opens  No Mass noted without difficulty

EYELASHES

Equally distributed

 No Lumps noted

Percussion

Auscultation

CONJUNCTIVA

Pale, moist

SCLERA

Opaque in color, c olor, moist

PUPIL

Pupil equally round reactive to light and accommodation, Constricts and dilates

IRIS

Dark brown in color 

LACRIMAL

Pale, no discharges

EXTRAOCULAR  Moves without EYE any difficulty, MOVEMENT follows the six cardinal gaze LIPS

Pale in color, c olor, symmetrical

 No mass noted

MOUTH

Gums are pale, fair in size, dry

 No mass noted

TONGUE

Pinkish in color, whitish palate  present

TEETH

Yellowish with a complete set of  teeth

PALATE

Hard and soft  palate are pale in color 

UVULA

Rises upon saying “ah”, medially located

TONSILS

Pale in color 

 NOSE

Has discharges, nasal mucus noted, centrally located, not  patent, septum located medially, no lesions, nasal flaring was not noted Symmetrical, ear  wax noted, can hear clearly, auricle aligned with outer  canthus

EARS

 NECK 

Brown in color, Carotid pulse: 78 symmetrical, can  beats per minute,  perform ROM no lumps noted exercises, lymph nodes are not inflamed

SKIN

Brown in color,  petechiae was noted in both lower and upper  extremities (pin  point like appearance), Temperature of  36.8 degree Celsius

EXTREMITIES: UPPER:

CHEST

Without IV, can  perform limited ROM exercises,  petechiae was noted (pin point like appearance) Equal chest expansion

Vibration felt upon tactile

RR: 24 breaths  per minute

BP: 100/60 mmhg

HEART

Clear breath sounds

LUNGS ABDOMEN

LOWER:

fermitus

Brown in color, no abdominal distention Can perform limited ROM exercises,  presence of   petechiae (pinpoint like appearance) on his both legs

Bowel sounds: 3 upon auscultation

III. Nursing Assessment 1. Personal History 1.1Patients Profile Name: Mr. Abella, Fernando Age: 50 years old Sex: Male Civil Status: Married Religion: Roman Catholic Date of Admission: February 04, 2007 Room No. : 532 Complaints: tonsillitis Diagnosis: Acute Myelogenous Leukemia Physician: Dr. Ponce, Susie 1.2Family and individual information, social and health history Mr. Abella, Fernando, 50 yrs. Old, male, Filipino Roman Catholic, who is married and has four children, all of which are still schooling. The patient works in a

government office. The patient is always exposed in petroleum products and paints. Mr. Abella is not hypertensive, diabetic and asthmatic. He is an occasional drinker and a positive smoker which he consumes one pack per day. Mr. Abella was rushed in the emergency room of Cebu Doctor’s University Hospital because he fainted and was very pale. He also complains of tonsillitis.

1.3. Level of growth and Development

Normal Development at Particular Stage

 The patient belongs to the middle adulthood. The middle years, from 40 – 65, have been called the years of stability and consolidation. For most people, it is a time when children have grown and moved away or are moving away from home. Thus, partners generally have more time for and with each other and time to pursue interests they may have deferred for years.   The middle adulthood, the individual makes lasting contributions through involvement with others. During this period, personal and career achievements have often already been experienced. Many middle adults find particular joy in assisting their children and other young people to become productive and responsible adults. They may also begin to help aging parents. Using leisure time in satisfying and creative ways is a challenge that, if met satisfactory, enables middle adults to prepare for retirement.

Men and women must adjust to inevitable biological changes. As in adolescence, middle adults use considerable energy to adapt self concept and body image to physiological realities and changes in physical appearance. High selfesteem, a favorable body image, and a positive attitude toward physiological changes are fostered when adults engage in physical exercise, balanced diet, adequate sleep, and good hygiene practices that promote vigorous, healthy bodies.

Physical Changes

A number of changes take place during the middle years. At 40, most adults can function as they did in their twenties. However during ages 40 – 65, many physical changes takes place. Both men and women experience decreasing hormonal production during the middle years. The menopause refers to the so called change of life in women, when menstruation ceases. It is said to have occurred when a woman has not had a menstrual period within a year. The menopause usually occurs anywhere between ages 40 – 55. The average is about 47 years. At this time, the ovaries decrease in activity until ovulation ceases. Psychologically, the menopause can be anxiety- producing time, especially if the ability to bear children is an integral part of woman’s self concept. The hair begins to thin and gray hair appears. Skin turgor and moisture decrease, subcutaneous fat decreases and wrinkling occur. Fatty tissue is redistributed, resulting in fat deposits in the abdominal area. Skeletal muscle bulk decreases at about age 60. Thinning of 

the intervertebral disk causes a decrease in height of about 1 inch. Calcium loss from bone tissue is more common among postmenopausal women. Muscle growth continues in proportion to use. Blood vessels lose elasticity and become thicker. Visual acuity declines, often by the late forties, especially for near vision (presbyopia). Auditory acuity for high- frequency sounds (presbycusis) also decreases, particularly in men. Taste sensations also diminish. Metabolism slows, resulting in weight gain. Gradual decrease in tone of large intestine may predispose the individual to constipation. Nephron units are lost during this time, and glomerular filtration rate decreases. Hormonal changes take place in both men and women.

Cognitive Changes

  The middle- aged adults’ cognitive and intellectual abilities change very little. Cognitive processes include the action time, memory, perception, learning, problem solving, and creativity. Reaction time during the middle years stays much the same or diminishes during the later part of the middle years. Memory and problem solving are maintained through middle adulthood. Learning continuous and cab be enhanced by increased motivation at this time in life. Middle-aged adults are able to carry out all the strategies described in Piaget’s phase of formal operations. The experiences of the professional, social, and personal life of middle-aged persons will be reflected in their cognitive performance.  Thus, approaches to problem solving and task completion will vary considerably in middle-aged group. The middle-aged adult can “reflect on the past and current experience and can imagine, anticipate, plan and hope”.

Changes in the cognitive function of middle adults are rare except with illness are trauma. The middle adult can learn new skills and information. Some middle adults enter educational or vocational programs to prepare themselves for entering the job market or changing jobs.

Moral Changes During this stage, rules and laws are valued because they maintain social order worth preserving. Morality is guided by higher principles of human conduct. Individuals appreciate the social purposes served by laws. They believe laws should be derived from a democratic consensus. Individuals search their own conscience for universal ethical principles. They do not make up their own rules but instead arrive at abstract principles that all religions or moral authorities might view as compelling or fair. There is a correlation between higher stages of reasoning and higher levels of moral behavior. According to Kohlberg, the adult can move beyond the conventional level to the post conventional level. Kohlberg believes that extensive experience of  personal moral choice and responsibility is required before people can reach the post conventional level. Kohlberg found that few of his subjects achieved the highest level of moral reasoning.

Psychosocial Development

 The psychosocial changes in the middle adult may involve expected events, such as marital separation. This change may result in stress that can affect the middle adults’ over all level of health. In the middle adult years, as children depart from the household, the family enters the post parental family stage. Time and financial demands on the parents decrease, and the couple faces the task of  redefining their own relationship. According to Eriksons’ developmental theory, the primary developmental task of the middle years is to achieve generativity. Generativity is the willingness to care for and guide others. If middle adults fail to achieve generativity, Stagnation occurs. This is shown by excessive concern with themselves or destructive behavior toward their children and community.

Spiritual Changes As man grows older he becomes more aware of the outside world. Some conform when they are forced to do so, some are driven by self interests and will do only what they must do to get what they want in return. They violate God’s law regularly, sinning more or less everyday with little remorse. Their spiritual senses are not alert. They are ignorant of God and have no concept of holiness. But as man grows older, he becomes more conscious of how important people really are. “Being good” is now important. He thinks about how other people see him and how they must feel. He realizes that the world runs according to rules. The desire to please

other drives him and when he fails his first response is to justify himself. This faith is based on the beliefs of the community. In adult life many individuals develop a faith that is purely their own individual faith and can deal with the paradoxes and ironies of human existence. A final stage of development finds some individuals making a commitment to universal values, such as love and justice. The focus on the value of experience and reflection and intellectual development finds a strong parallel in the importance given to the rule of experience and reflection in spiritual growth.

Sexuality Changes After the departure of their last child from the home, many couples recultivate their relationships and find increased marital and sexual satisfaction during middle age. The onset of menopause and the climacteric can affect the sexual satisfaction during the middle adult. Other factors influencing sexuality during this period include work stress, diminished health of one or both partners, and the use of prescription medications.

Diagnostic Test

Normal Value

Result

Significance

Hemoglobin

14-17.5gm/dL

6.77gm/dL

Hematocrit

14-17.5

19.3

4.4-11.0

174,000

3%

02%

56%

05%

0.3%

--

2.7%

--

34%

07%

WBC Band Segmenter  Basophil Eosnophil

Increased: Infection Decreased: Decreased:  NORMAL  NORMAL Decreased: Immuno – 

Lymphocyte 4%

61%

4.5-5.9 10 12/L

1.93 10 12/L

80-96fL

100fL

Monocyte

RBC

Decreased: Anemia Increased: Erythrocytosis

MCV 27.5-33.2pg

35.1 pg

MCH 33.4-35.5%

MCHC

--

MPV

--

RDW

150,000-

Platelet Count

450,000/cu mm

0.5-1.5%

Reticulocyte

0.00-20.00mm/h

ESR 

0.7-1.5mg/dL

Creatinine Serum

3.6-5.0mmol/L

Potassium

11-66uL

ALT

137-145mmol/L

Sodium 2.5-7.5mg/L

35.0% ---

deficiency Increased: Viral infections Decreased: Anemia Increased: Macrocytic Anemia Increased: : Macrocytic Anemia  NORMAL  NORMAL  NORMAL

27,020/cu mm Decreased: Acute Leukemia

--2.1 mg/dL 3.0 mmol/L 59 uL

 NORMAL  NORMAL Increased: Fever  Decreased: Diarrhea

134 mmol/L  NORMAL

11.9 mg/L

Decreased: Metabolic Acidosis Increased: Gout

Uric Acid

Present Profile of the Functional Health Patterns

3.1 Health Perception Pattern Before the patient was diagnosed with Acute Myelogenous Leukemia the patient describes himself as a healthy individual. But as of now, he describes his condition as very poor due to his present condition. In order for him to keep healthy, he must eat nutritious foods and must not over fatigue himself. He follows the doctors order and take the medication as needed. The patient refuses to have chemotherapy due to financial problems.

3.2 Nutritional Metabolic Pattern Before the patient was not admitted in the hospital, he likes to eat any kind of foods. But as of now, the patient does not want to eat and he vomits all the time. The patient drinks alcohol mostly everyday, he prefers to drink Tanduay and Emperador. The patient also smokes and can consume one pack per day. The patient takes vitamin supplements like Revicon and Everet. According to the patient his weight had decreased from 180 pounds to 110 pounds.

3.3 Elimination Pattern On the first week of his admission, the patient was having hematuria and melena. After the following weeks, the patient’s foley bag catheter was

already removed and the patient was having no problems in urinating and defecating. The patient defecates once in a day. 3.4 Activity or Exercise Pattern Before, the patient used to walk from his home to his office, but now even five steps he feels fatigue and will have a difficulty in breathing. The patient was advised by the physician not to over fatigue himself and he needs enough sleep and rest.

3.5 Cognitive or Perceptual Pattern  The patient cannot see from far objects. He wears eyeglasses so that he can see clearly. The patient can hear well enough. The patient often times complains of  fatigue and feels drowsy all the time. The patient is able to read and write.

3.6 Sleep or rest Pattern Before the patient’s hospitalization, he sleeps at 7: 00 pm to 6:00 in the morning, but now because of his condition he sleeps most of the time. The patient has no problem in sleeping.

3.7 Self Perception Pattern  The patient is concerned about his illness. He is scared that he will die and might be far away from his family. According to the patient, he wants to be free

from Leukemia but it is too impossible to happen, it needs some miracles. The patient describes himself as very religious especially with his condition and he must need some faith to hold on to whatever circumstances might happen. His condition made him different because unlike normal people he needs to wear a mask all the time.

3.8 Role Relationship Pattern  The patient prefers to speak Cebuano. He speaks clearly and fluently and he is able to express himself freely. The patient lives with his family in Matabang Toledo City.

3.9 Coping or stress Tolerance Pattern   The patient and his wife both make the decision especially when it comes to health and financial matters. He sometimes seeks help to his mother when it comes t o problem solving because he is more comfortable in asking for assistance so that he can express his feelings. The patient is still working but he will  just go to work to punch in and leave.

3.10 Value or belief System  The patient is a Roman Catholic and God is very important to him. For him, God and his family is his source of strength and meaning. The patient prays the rosary and attends mass every Sunday. The patient wishes to go to Simala to

pray for his condition. According to the patient, he just accepts what Gods plan awaits him.

IV. Pathophysiology and Rationale

Anatomy and Physiology

 The immune system defends the body from invading organisms that may cause disease. One part of the immune system uses barriers to protect the body from foreign substances. These barriers include the skin and the mucous membranes, which line all body cavities; and protective chemicals, such as enzymes in saliva and tears that destroy bacteria. Another part of the immune system uses lymphocytes, specialized white blood cells that respond to specific types of foreign invaders. B lymphocytes produce proteins called antibodies, which circulate in the blood and attack specific disease-causing organisms. T lymphocytes attack invading organisms directly.

COMPONENTS OF THE IMMUNE SYSTEM Macrophage Engulfing Bacterium

A macrophage, in yellow, engulfs and consumes a bacterium. Macrophages are large phagocytes, cells that wander through the body consuming foreign particles such as dust, asbestos particles, and bacteria. They help protect the body against infection.

White blood cells are the mainstay of the immune system. Some white blood cells, known as macrophages, play a function in innate immunity by surrounding, ingesting, and destroying invading bacteria and other foreign organisms in a process called  phagocytosis (literally, “cell eating”), which is part of the inflammatory reaction. Macrophages also play an important role in adaptive immunity in that they attach to invading antigens and deliver them to be destroyed by other components of the adaptive immune system.

LYMPHOCYTE

Lymphocytes are specialized white blood cells whose function is to identify and destroy invading antigens. All lymphocytes begin as “stem cells” in the bone marrow, the soft tissue that fills most bone cavities, but they mature in two different places. Some lymphocytes mature in the bone marrow and are called B lymphocytes. B lymphocytes, or B cells, make antibodies, which circulate through the blood and other body fluids, binding to antigens and helping to destroy them in humoral immune responses. Other lymphocytes, called T lymphocytes, or T cells, mature in the thymus, a small glandular organ located behind the breastbone. Some

  T lymphocytes, called cytotoxic (cell-poisoning) or killer T lymphocytes, generate cell-mediated immune responses, directly destroying cells that have specific antigens on their surface that are recognized by the killer T cells. Helper T  lymphocytes, a second kind of T lymphocyte, regulate the immune system by controlling

the

strength

and

quality

of

all

immune

responses.

Most contact between antigens and lymphocytes occurs in the lymphoid organs— the lymph nodes, spleen, and tonsils, as well as specialized areas of the intestine and lungs (see Lymphatic System). Mature lymphocytes constantly travel through the blood to the lymphoid organs and then back to the blood again. This recirculation ensures that the body is continuously monitored for invading substances.

BONE MARROW

Bone Marrow, soft, pulpy tissue that fills the cavities of bones, occurring in two forms, red and yellow. One of the largest tissues in the body, bone marrow accounts for 2 to 5 percent of  an adult’s weight. Red marrow, present in all bones at birth, serves as the blood manufacturing

center. As an infant matures, most of the red marrow in the shaft of long bones, such as the arm and leg bones, is gradually replaced by yellow marrow. Yellow marrow is composed primarily of  specialized fat cells.

STRUCTURE

Red marrow consists primarily of a loose, soft network of blood vessels and protein fibers interspersed with developing blood cells. The blood vessels are termed the vascular  component, and the protein fibers and developing blood cells collectively are referred to as the stroma, or the extravascular component. The protein fibers crisscross the marrow, forming a meshwork that supports the developing blood cells clustered in the spaces between the fibers. Red marrow contains a rich blood supply. Arteries transport blood containing oxygen and nutrients into the marrow, and veins remove blood containing carbon dioxide and other wastes. The arteries and veins are connected by capillaries, blood vessels that branch throughout the marrow. In various places, the capillaries balloon out, forming numerous thin, blood-filled cavities. These cavities are called sinusoids, and they assist in blood-cell production.

Yellow marrow is so named because it is composed of yellow fat cells interspersed in a rich mesh of connective tissue that also supports many blood vessels. While not usually actively involved in blood formation, in an emergency yellow marrow is replaced by blood-forming red marrow when the body needs more blood

MARROW FUNCTION

Red marrow produces all of the body’s blood cells—red blood cells, white blood cells, and platelets. Red blood cells in the circulatory system transport oxygen to body tissues and

carbon dioxide away from tissues. White blood cells are critical for fighting bacteria and other  foreign invaders of the body .Platelets are essential for the formation of blood clots to heal wounds. Within red bone marrow, all blood cells originate from a single type of cell, called a hematopoietic stem cell. Stimulated by hormones and growth factors, these stem cells divide to  produce immature, or progenitor blood cells. Most of these progenitor cells remain in the stroma and rapidly undergo a series of cell divisions, producing either red blood cells or white blood cells. At any one time, the stroma consists largely of progenitor cells in various stages of  development. At the appropriate developmental stage, the fresh, new cells squeeze through the walls of the capillaries. From there, the cells leave the bone and enter the body’s circulatory system. Some progenitor cells migrate to the sinusoids, where they produce platelets, which also travel to the circulatory system via the capillaries. Although stem cells are relatively rare—about 1 in every 10,000 marrow cells is a stem cell—they typically produce the forerunners of an estimated 2 million red cells per second and 2 billion platelets per day. However, if significant amounts of blood are lost or other conditions reduce the supply of oxygen to tissues, the kidneys secrete the hormone erythropoietin. This hormone stimulates stem cells to produce more red   blood cells. To fight off infection, hormones collectively termed colony stimulating growth  factors are released by the immune system. These hormones stimulate the stem cells to produce more infection-fighting white blood cells. And in severe cases, the body converts yellow marrow into red marrow to help produce needed blood cells.

PREDISPOSING FACTORS

4.3 Discuss the disease process ands its effects on different organ/system

Leukemia Overview CANCER  Cancer  is a process of uncontrolled abnormal cell growth and development. Under  normal circumstances, cells are formed, mature, carry out their intended function, and then die.  New cells are constantly regenerated in the body to replace those cells and to maintain normal cellular function. Cancer represents the disturbance of this process, which can occur in several ways.Cells may grow and reproduce in a disorganized and out-of-control fashion. Cells may fail to develop properly, so they will not function normally. Cells may fail to die normally. One or a combination of these processes may occur when cells become cancerous.

LEUKEMIA Leukemia is a cancer of blood-forming cells in the bone marrow. These deranged, immature cells accumulate in the blood and within organs of the body. They are not able to carry out the normal functions of blood cells.  Normal blood contains 3 major groups of cells: white blood cells, red blood cells, and platelets. All 3 types of blood cells develop from one immature cell type, called blood/marrow stem cells, in a process called hematopoiesis. •

 These stem cells divide and develop to a more developed, but still immature precursor, called a blast, which then develops through several more stages, into a mature blood cell.

•

  This process takes place in the bone marrow, which is the soft spongy material found in the center of most bones.

Each type of blood cells has its own different and essential function in the body. •

White blood cells (leukocytes) are part of the immune system and help fight a variety of infections. They also help in the healing of wounds, cuts, and sores.

•

Red blood cells (erythrocytes) contain hemoglobin, which carries oxygen to, and removes carbon dioxide from, the cells throughout the various organs of  the body.

•

Platelets, along with certain plasma proteins, help plug the holes in blood vessels and form clots once blood vessels are damaged or cut.

 The first step in the process of stem cell maturation is differentiation into 2 groups: the myeloid stem cell line and the lymphoid stem cell line. •

 The myeloid stem cells, or lineage, develop into red blood cells, platelets, and certain types of white blood cells (granulocytes or monocytes).

•

 The lymphoid stem cells, or lineage, develop into another type of white blood cell (lymphocytes).

•

Either lineage can be affected by leukemia. Leukemias that affect the myeloid lineage

are

called

myelocytic

(also

myelogenous,

myeloblastic,

or

nonlymphocytic) leukemias. Leukemias that affect the lymphoid lineage are called lymphocytic (also lymphoblastic or lymphogenous) leukemias. Each of the 2 major types of leukemia, myelogenous and lymphocytic, include both acute and chronic forms. •

Acute essentially refers to a disorder of rapid onset. In the acute myelocytic leukemias, the abnormal cells grow rapidly and do not mature. Most of these immature cells tend to die rapidly. In the acute lymphocytic leukemias, growth is not as rapid as that of the myelocytic cells. Rather, the cells tend to accumulate. Common to both types of leukemia is their inability to carry out the functions of healthy white blood cells. Untreated, death occurs within weeks or a few months.

•

In the chronic leukemias, the onset tends to be slow, and the cells generally mature abnormally and often accumulate in various organs, often over long intervals. Their ability to fight infections and assist in repairing injured tissues is impaired. However, unlike the acute forms of leukemia, untreated, these disorders may persist for many months or, as in the chronic lymphocytic group, many years. A distinctive feature of the chronic myelocytic type is its invariable conversion, if untreated, to a more rapidly fulminating acute type, leading to rapid death.

WHAT HAPPENS IN LEUKEMIA? When a large number of blasts (leukemic cells) appear in the bone marrow, several things happen. As the leukemic blast cells accumulate in the bone marrow, they begin to crowd out the normal blood cells that develop there. Eventually, they take up so much room that red blood cells, platelets, and normal white blood cells cannot be produced. When that happens, the young person develops symptoms indicating that normal blood cells are not being manufactured in adequate numbers: •

If red blood cells are crowded out by leukemic cells, the blood will look thin, which makes the patient look pale. The young person also may be tired,

because the thin blood cannot carry enough oxygen to the heart, lungs, and muscles. •

If blood platelets are crowded out in the bone marrow, the young person may have bleeding problems and unusual bruising.

•

If the normal, mature kind of white cells known as neutrophils are crowded out by the blasts, there will be no cells to combat bacteria, and infections may occur. In some cases, leukemic blasts may spill over from the bone marrow into the blood, where they can be seen by microscopic examination. This may cause a rise in the number of white cells in the blood (the white blood cell count). In other cases, only a few blasts appear in the blood, and the white cell count does not change much. When leukemic blasts are present in the blood, they may be carried to other places in the body and enter various body organs. Sometimes they grow in these organs as well as in the bone marrow.

Cancer cells

ACUTE MYELOGENOUS LEUKEMIA

Normal cells

A PICTURE OF ACUTE MYELOGENOUS LEUKEMIA Acute myelogenous leukemia (AML) is a cancer of the blood and bone marrow — the spongy tissue inside bones where blood cells are made.

It's called acute leukemia because it progresses rapidly and affects immature blood cells, rather than mature ones. It's called myelogenous (MI-uh-loj-uh-nus) leukemia because it affects a group of white blood cells called the myeloid cells, which normally develop into the various types of mature blood cells, such as red blood cells, white blood cells and platelets. This type of  leukemia is also known as acute myeloid leukemia, acute myeloblastic leukemia, acute granulocytic leukemia and acute nonlymphocytic leukemia.  Normally, your bone marrow produces immature cells (stem cells) in a controlled way, and they mature and specialize into the various types of blood cells as needed. In people with acute myelogenous leukemia, the bone marrow produces immature cells that usually develop into a type of abnormal white blood cell. These abnormal cells aren't able to mature and perform their  usual functions. Even worse, they multiply rapidly and can crowd out healthy cells, leaving a   person with acute myelogenous leukemia vulnerable to infection, anemia or easy bleeding. Leukemia cells can also spread outside the blood to other parts of your body.Acute myelogenous leukemia is the most common form of leukemia. It worsens quickly if not treated, but it initially responds well to treatment. Unfortunately, many people with acute myelogenous leukemia experience a relapse. Much research is focused on decreasing the risk of relapse and improving the long-term outcomes for people with acute myelogenous leukemia CAUSES

The cause of acute myelogenous leukemia is damage to the DNA of developing cells in your bone marrow. Under normal circumstances, your DNA is like a set of instructions for your  cells, telling them how and when to grow and divide. Certain genes on your DNA called oncogenes promote cell division. Other genes, called tumor suppressor genes, slow down cell division and cause cells to die at the appropriate times. Acute myelogenous leukemia can occur when damage to DNA turns on oncogenes or turns off  tumor suppressor genes. When this happens, blood cell production goes awry. The bone marrow  produces immature cells that develop into leukemic white blood cells called myeloblasts. These abnormal cells are unable to function properly, and they can build up and crowd out healthy cells.The DNA mutations that cause leukemia are usually acquired — rather than inherited —   but researchers and doctors don't always understand exactly how. In some cases, damage to DNA is the result of exposure to cancer-causing chemicals, including previous chemotherapy for other  cancers. There's also a chance of AML progressing from other blood diseases and chronic leukemias, such as chronic myelogenous leukemia, myelodysplasia or other disorders in which the bone marrow produces too much of certain types of blood cells (myeloproliferative disorders).

RISK FACTORS The risk of acute myelogenous leukemia increases with age. It's most prevalent in people in their 60s and older. The disorder is also more common in males than in females. Other possible risk factors include: •

Cancer therapy. People who've had certain types of chemotherapy and radiation therapy or treatment for childhood acute lymphocytic leukemia (ALL) may have a greater risk of developing AML.

•

Exposure to radiation and certain chemicals. People exposed to very high levels of radiation, such as survivors of an atomic bomb blast or a

nuclear reactor accident, have an increased risk of developing AML. Exposure to certain chemicals, such as benzene — which is found in unleaded gasoline and used by the chemical industry — also is linked to greater risk of AML. •

Smoking. AML is linked to cigarette smoke, which contains benzene and other known cancer-causing chemicals. Smokers older than 60 face twice the risk of AML that nonsmokers do.

•

Other blood disorders. People who've had another blood disorder, such as myelodysplasia, polycythemia vera or thrombocythemia, are at greater risk of  developing AML.

•

Genetic disorders. Certain genetic disorders, such as Down syndrome, are associated with an increased risk of AML.

CLASSICAL SYMPTOMS

CLINICAL SYMPTOMS

RATIONALE

Anemia

•

•

•

Manifested

Dyspnea

During the assessment,

Fatigue

the student nurse

Pale skin, mucous membrane, conjunctiva, nail beds

observed that the patient has a pale skin, oral mucosa, conjunctiva and nail beds. The patient also verbalizes that he feels weak and sometimes he had difficulty in breathing even doing things with no exerted force.

More specific signs and symptoms of acute myelogenous leukemia are caused by a lack of  properly functioning blood cells, resulting from overcrowding by leukemia cells. The oxygen carrying capacity of hemoglobin is reduced causing tissue hypoxia and can result to fatigue, weakness and dyspnea (p. 276 disease management for nurse practitioner by: Scilling) In acute melogenous leukemia, there is the loss of bone marrow

Thrombocytopenia Manifested

function because of the  The patient had a low platelet count levels

replacement of the malignant cells such as

(27,020cu mm)

occurs in leukemia, which results in decrease production of  platelets (p. 265 disease management for nurse practitioner by: Scilling) In acute myelogenous leukemia, bleeding is evident because of a

•

Bleeding

Manifested

decrease circulating platelets or impaired

One week prior to admission, the patient experiences hematuria and bloody stools. The patient also has petechiae in his surrounding skins.

platelet function. Bleeding that results from platelet deficiency commonly occurs in small vessels and is characterized by petechae and purpura (p. 265 disease management for nurse practitioner by: Scilling)

In acute myelogenous leukemia, the bone marrow produces immature cells that Manifested

usually develop into a type of abnormal white

Neutropenia

 The patient was advised blood cell. These

•

infection

by his physician to wear abnormal cells aren't mask all the time and able to mature and must eat foods that ca perform their usual boost his immune functions. Even worse, system they multiply rapidly and can crowd out healthy cells, leaving a person with acute myelogenous leukemia vulnerable to infection (http://www.mayoclinic.c om)  The symptoms of AML are caused by low numbers of healthy Manifested

blood cells and high numbers of leukemia

 The patient had fever

•

fever

one week prior to his

cells. White blood cells

admission because of 

fight infection. Low

massive tonsillitis

numbers can lead to fever and frequent infections. With immunosuppression the body the body is often unable to respond an infection with a characteristic indicator, such as fever (http://www.marrow.org) (p. 660 Nursing Care of  acutely ill and chronically ill patient by: Lagerquist)

In patient who is immune-suppressed, the oral mucous membranes Manifested  The patient complains of  having difficulty in

are often a source of  infection; therefore a complain of a sore throat is an important of 

•

tonsillitis

swallowing because of 

early indication of a

tonsillitis.

potential problem

(p. 660 Davis’s NCLEXRN Success by: Lagerquist)  These is because of the proliferation of leukemia cells within organs

Not Manifested

(p. 897 medical- surgical nursing by: Brunner)

Not Manifested Not Manifested

Spleenomegaly Hyperplasia of the gums Bone pain

Nursing Interventions

1. Care Guide in Patient with disease Condition

TREATMENT

Treatment of patients with acute myelogenous leukemia depends on age and the subtype of  the disease. In general, treatment falls into two phases:

•

Remission induction therapy. The purpose of the first phase of treatment is to kill the leukemia cells in your blood and bone marrow. However, remission induction usually doesn't wipe out all of the leukemia cells, so you need further treatment to prevent the disease from returning.

•

Consolidation therapy. Also called post-remission therapy, maintenance therapy or intensification, this phase of treatment is aimed at destroying the remaining leukemia cells. It's considered crucial to decreasing the risk of  relapse.

Therapies used in these phases include:

•

Chemotherapy. Chemotherapy is the major form of remission induction therapy. A

common course of therapy involves two chemotherapy drugs — cytarabine (Cytosar-U), followed by an anthracycline drug, such as daunorubicin (Cerubidine) or idarubicin (Idamycin). A third medication, thioguanine, is sometimes used.

If you have AML, you'll probably stay in the hospital during the treatment cycle because the chemotherapy destroys many normal blood cells in the process of killing leukemia cells. This chemotherapy can cause anemia, infection and bleeding. If the first cycle of  treatment doesn't cause remission, you may need it repeated one or two more times. Other drug combinations also may be used, depending on your specific situation.

Chemotherapy can also be used for consolidation therapy. This phase may include a combination of different medications that mimic the induction, but usually includes high doses of cytarabine by itself for one to three cycles. Your doctor may also prescribe medications that boost white cell production to reduce the risk of infection. These medications are called granulocyte colony stimulating factors (Neupogen, Leukine).

•

Other drug therapy. Arsenic trioxide and all-trans retinoic acid (ATRA) are anti-cancer drugs that can be used alone — or in combination with chemotherapy — for remission induction of a certain subtype of AML called promyelocytic leukemia. These drugs cause leukemia cells with a specific gene mutation to mature and die, or to stop dividing.

•

Biological therapy. Also known as immunotherapy, biological therapy uses substances that

bolster

your immune system's response

to cancer.

Monoclonal antibodies are one form of biological therapy. These antibodies are produced in a laboratory, but they mimic protein products found in your immune system (antibodies) that attack foreign substances (antigens) on leukemic cells. Gemtuzumab ozogamicin (Mylotarg) is a monoclonal antibody linked to a chemical toxin that attaches to AML cells. It's used to treat older people with AML who don't respond to initial treatment or who relapse after successful initial treatment. Researchers are testing its effectiveness in younger people with AML. •

Bone marrow transplant. This is another option for consolidation therapy for people at high risk of relapse or for treating relapse when it occurs. This procedure allows someone with leukemia to re-establish healthy stem cells by replacing their leukemic bone marrow with leukemia-free marrow. If you

choose this treatment, you'll receive very high doses of chemotherapy or radiation therapy to destroy your leukemia-producing bone marrow. This marrow is then replaced by bone marrow from a compatible donor (allogeneic transplant). In some cases, you may also be able to use your own bone marrow for transplant (autologous transplant). This is possible if you go into remission and then save healthy bone marrow for a future transplant. •

Stem cell transplant. Stem cell transplant is also used for consolidation therapy. It's similar to bone marrow transplant except the stem cells are collected from circulating blood (peripheral blood), rather than from the bone marrow, thanks to a medication that causes larger numbers of stem cells to be released from the bone marrow. The cells used for transplant can be your own healthy cells, or they can be collected from a compatible donor. This procedure is used more frequently than bone marrow transplant because of  shortened recovery times and possible decreased risk of leukemia recurrence.

•

Radiation Therapy .Radiation therapy involves the use of radiation to kill cancer cells

and shrink tumors. For AML, external radiation therapy is used.In external radiation therapy radiation is directed at the tumor from a source outside the body. This type of  treatment is used for AML that has spread—or may spread—to the brain and spinal cord. It can also be used to treat bone pain that comes from bone affected by the leukemia.

NCP

s- “ dali na kayo ko kutasan ug kapuyan na ko dae, mga lima ka lakang kapuyon na ko” as verbalized by the patient

o-

weakness

-feeling of exhaustion -low RBC counts: 1.93 - low hemoglobin count: 6.77 -shortness of breath -fatigue -blood pressure: 100/60 mmhg

A-

Activity Intolerance: fatigue related to anemia

P-

demonstrate a decrease in physiologic signs of intolerance

I-

plan care with rest periods between activities

elevate head of bed as tolerated

provide positive atmosphere, while acknowledging difficulty of the situation of  the patient

provide quiet environment, maintain bed rest as indicated. Limit visitors, phone calls and reported unplanned interruptions

prioritize nursing care schedules to enhance rest.

use energy techniques such as shower chair, sitting performing task

provide assistance with patient, including activities that the patient views as essential. Increase activity levels as tolerated

instruct patient to stop activity if palpitations, chest pains, shortness of breath, weakness, dizziness occur

change patient position slowly and monitor for dizziness

E-

the patient shows a decrease signs of intolerance

s-

“ ingon si doc dae na pa mason ko niya kai para dili ko ma takdan sa mga

sakit” As verbalized by the patient

o-

increase white blood cells:174,000

presence of immature leukocytes compromised immunity wears mask low eosinophil: 0% low lymphocyte: 07%

A-

Risk for infection related to proliferation of immature lymphocytes

P-

the client will be free from acquiring infection

I-

maintain a fluid intake of at least 2500 ml per day

use good handwashing technique and encourage patient to do the same

protect client from others with infections

instruct and assist client to perform good oral hygiene as often as needed

instruct patient to wear mask all the time

eliminate fresh salads and unpeeled fresh fruits and vegetables

allow no fresh flowers

administer antimicrobials as needed

E-

the patient shows a decrease signs of intolerance

s-

“ pait kaau ning akong kahimtang, naa pa koi mga anak nga gagmay sa tanan

ako pa jd wala mn me kwarta” As verbalized by the patient

o-

sad facial expression crying

A- Anticipatory grieving related to possible loss of loved one P-

will be able to express feelings of anxiety

I-

encourage verbalization of fears, concerns and questions regarding disease

treatment

encourage active participation of patient or family in care and treatment decisions

be with patient most of the times

encourage verbalization of negative feelings, including anger and hostility

allow periods of crying and expression of sadness

use therapeutic communication skills of active listening, silence, acknowledgement

advise for professional counseling

permit verbalization of anger with acknowledgement of feelings and setting of  limits regarding destructing behavior

E-

the patient was able to verbalize feelings of anxiety

OBJECTIVES

CONTENTS

METHODOL OGY

GOAL: After 3 days of varied teaching and learning experience, the patient and significant others will  be able to gain knowledge, attitude and skills about his disease condition and how to prevent fatigue. After 45 minutes of  student nurse-patient interaction, the patient will be able to: 1. identify  predisposing factors in acquiring leukemia

2. enumerate signs and symptoms of  leukemia

1. predisposing factors in acquiring leukemia 1.1 expose to radiation for a long period 1.2 genetic factors such as down syndrome 1.3 exposure to chemicals such as benzene and drugs that causes aplasic anemia

Informal discussion

Informal 2. signs and symptoms of  discussion leukemia 2.1 fever and infection related to decrease in white blood cells 2.2 weakness and fatigue from anemia 2.3 bleeding tendencies from decreased platelets

EVALUATION

3. determine the significance on wearing a mask all the time 4. the patient will show interest during the health teaching

5. demonstrate  beginning skills on  preventing fatigue by clustering scheduled activities

3. significance on wearing Informal mask all the time discussion 3.1 this is to prevent the  patient from acquiring any infection 4. shows interest during the Informal health teaching discussion and 4.1 asks questions during the utilization of  interaction of the student  pictures nurse 4.2 participates and encourages the student nurse to go on to the discussion 4.3 Shows interest on the discussion by cooperating with the student nurse 5. clustering scheduled activities 5.1 teach client on how to cluster activities to  prevent fatigue example: Monday: 7:00-7:30 (eating breakfast) 7:30 – 9:00 watching television for relaxation 9:00-9:30 perform exercise such as walking 9:30-10:00 reading  books … 5.2 let the patient decide and schedule his planned activities

Scheduling activities and Informal discussion

VII. Evaluation and Recommendation:

Early detection of an ailment is vital to the patient.

Oftentimes lack of in-depth

knowledge regarding a condition of a disease may hinder a patient in seeking immediate advice from medical specialist. Fear and financial problems may sometimes interfere which may often lead to the severity of the disease. This I believe is one of the major causes as to why my patient has gone to this terminal stage of his Acute Myelogenous Leukemia (AML). The nature of his job as a painter exposes him to great risk of an organ damage. Petroleum products when exposed to a person to a considerable period of time may often lead a person to this problem. This is also coupled with lack of knowledge regarding this health hazard. According to his recent laboratory results, his platelet is 27,000 /cu mm which is very low compared to the normal platelet count of 150,000-450,000/ cu mm. This shows a decrease in  both platelets and erythrocytes. The patient shows hematuria, melena and petechiae on his both upper and lower extremities, this is an indication of decrease in platelet as well. Because of lack  of mature and normal granulocytes, the patient had a massive tonsillitis. Since treatment for  chemotherapy is too costly for the patient this could contribute for a compelling severity of his health condition. It is necessary to undertake sessions of chemotherapy to prolong the patient’s life. Immaturity of leukocytes can also lead to severe infection, the patient is encouraged to wear  mask whenever the condition necessitates. The patient needs proper rest due to fatigue. He also needs more encouragement from his immediate family member, relatives and friends.

Government sector plays a great role in sustaining financial support for indigent patients. Health care institutions can also help in the financial assistance of their members. Advancement of medical technology and profession is always a mileage in the science of medical world.

DTR

VII. Bibliography

Porth, Carolwatson.” Pathophysiology”.6th edition. Schilling, Judith A. RN, MSN “ Disease management for Nurse Practitioners”. Smeltzer, Suzanne. Bare, Brenda. “Medical-Surgical Nursing. 10th edition. Lippincott Wiliams and Wilkins. Lagerquist, Sally. “ Nclex-RN Success” F.A. Davis Company Marieb, Elaine. “Essentials of Human Anatomy and physiology” education Inc., San Francisco, California. 2003. Smeltzer. Bare. “ Medical-Surgical Nursing”. 10th edition. Patrick. “ Medical-Surgical Nursing”. 2nd edition. Phipps. Long. Woods. “Medical-Surgical Nursing”

INTERNET: http://healthgate.partners.org www.mayoclinic.com www.cancerlinkusa.com www.niaid.nih.gov] Microsoft encarta 2006 PremiuM

7th edition.Pearon