Veronica Castellanos, SN May 25, 2011 Chapter 31: Hematologic Problems CASE STUDY LEUKEMIA PATIENT PROFILE: JJ,

is a 35 year old white man went to the ER because of severe bruising cause by a fall while hiking. SUBJECTIVE DATA: Complains for oral pain and white patches covering his tongue. Has had a 2-month history of fatigue, malaise, and flu symptoms. Has taken numerous prescribed antibiotics and increased rest and sleep in the past 2 months without relief of symptoms. OBJECTIVE DATA: Has bruises and ecchymoses from fall. Gingiva has petechiae and patchy white spots, Temperature 102.2F. Has splenomegaly. Hematocrit 30%, Hb 8.8g/dl, WBC count 120,000, Platelet count 25,000. Bone marrow biopsy showed multiple myeloblasts (greater than 50%) QUESTIONS: 1. What component of the laboratory test results suggested acute leukemia? Low RBCs, low to high WBCs with a left shift. A left shift is an increase in the number of immmature neutrophils or polymorphonuclear leukocytes (PMN's). These are called band or stab neutrophils, and in more severe cases there may be metamyelocytes or myelocytes present. Mature (normal) neutrophils are referred to as segmented neutrophils or segs. In a normal differential there should be 0-6 bands per 100 WBC's and no metamyelocytes or myelocytes.

2. How is acute myelogenous leukemia treated? Initial emergent treatment may employ the use of leukapheresis (blood is drawn from one arm with the help of a catheter that is placed in one of the veins. The blood is then removed from the arm and placed into a centrifuge. The centrifuge spins the blood and separates it into various components according to the materials weight and density. Consequently, the blood can be separated into red blood cells, white blood cells, and platelets. Typically, the white blood cells are removed and the rest of the cells and the blood plasma are returned to the body through another catheter or a needle in the opposite arm) and hydroxyurea (a chemotherapy agent with potent effects on the bone marrow). Cytotoxic chemotherapy is the mainstay of treatment. The first stage, induction therapy, is the attempt to induce or bring about a remission. This is an aggressive treatment that seeks to destroy leukemic cells in the tissues, peripheral blood, and bone marrow in order to eventually restore normal hematopoiesis. The purpose of these treatments is to reduce the WBC count and risk leukemia induced thrombosis. Collaborative care is focused on the initial goal of attaining remission.

3. What is the prognosis for JJ? The prognosis is directly related to the ability to maintain remission. The prognosis becomes more unfavorable with each relapse. Each time there is a relapse, the succeeding remission may be more difficult to achieve and shorter in duration. After one course of induction therapy, approximately 70% of newly diagnosed patients achieve complete remission. Post-induction chemotherapy is used in many cases because leukemic cells persist undetected after induction therapy.

4. What are the main priorities for patient teaching with a newly diagnosed young adult with leukemia? Help patient realize that although the future maybe uncertain, one can have a meaningful quality of life while in remission or with disease control, and that, in some cases, there is a reasonable hope for cure. Instruct the patient on the purpose and action of each medication. Instruct the patient on dosage, route, and duration of each medication to improve compliance. Instruct the patient on possible adverse effects of each medication. A patient empowered by knowledge of the disease and treatment can have a more positive outlook and improved quality of life.

5. What are the life-threatening problems that can occur as a result of this disease and treatment? How can the nurse anticipate and assess for these problems? During induction therapy a patient may become critically ill because the bone marrow is severely depressed by the chemotherapeutic agents. Nurses focus on bone marrow suppression which is neutropenia, thrombocytopenia, and anemia. Additional complications of chemotherapy may affect the patients GI tract, nutritional status, skin and mucosa, cardiopulmonary status, liver, kidneys, and neurologic system. The nurse can anticipate and assess for these problems by being knowledgeable about all the drugs being administered. This includes the mechanism of action, purpose, potential side effects, safe-handling considerations, and toxic effects.

6. Based on the assessment data presented, write one or more nursing diagnoses. Are there any collaborative problems? Activity intolerance, altered nutrition: less than body requirements related to oral pain, impaired oral mucous membrane related to petechiae and oral candida, risk for injury related to fatigue and malaise, and risk for infection. The needs of a patient with leukemia are best met by multidisciplinary team (e.g psychiatric and oncology clinical nurse specialists, case managers, dieticians, chaplains, and social workers)