I.

DEMOGRAPHIC DATA
NAME : M.W.T.
AGE : 25 Years old
BIRTHDATE : March 14, 1989
SEX : Female
CIVIL STATUS : Single
OCCUPATION : Nurse - all en!er "gen!
ATTENDING PHYSICIAN : #r. Ma!!he$ %o Ya&
SOURCE OF INFORMATION : 4'( - har!
4'( - Signi)ican! *!her +Mo!her,
2'( - -a!ien!
II. PATIENTS HISTORY
-a!ien! is a diagnosed case o) T-cell "cu!e ./m&hoc/!ic .eu0emia since 1ul/ 2'14 and is
undergoing chemo!hera&/ $i!h .anase and 2incris!ine. She had a ches! !horaco!om/ !u3e
inser!ion on "ugus! 11, 2'14 in her righ! lung a! e3u 2ele4 %eneral 5os&i!al.
6n 1anuar/ 2'14, 7 mon!hs &rior !o admission, &a!ien! $as diagnosed $i!h Medias!inal
./m&homa and had a ches! !horaco!om/ !u3e inser!ion in her le)! lung a! -er&e!ual Succour
5os&i!al.
*ne nigh! &rior !o admission, &a!ien! had e&igas!ric &ain, 3urning !/&e, $i!h a &ain score o)
1' ou! o) 1', radia!ing !o !he 3ac0, associa!ed $i!h 8 e&isodes o) 9omi!ing es!ima!ed !o 3e 1:4
cu& in amoun! &er e&isode, usuall/ sali9ar/ in con!en!s.
*n !he da/ o) admission, &a!ien! had &ersis!en! e&igas!ric &ain $i!h 1 e&isode o)
9omi!ing $i!h sali9ar/ con!en!s, $hich &rom&!ed !hem !o ha9e a consul!a!ion $i!h !he a!!ending
&h/sician. The/ $ere !hen ad9ised )or admission. ;&on admission, &a!ien! had 2 e&isodes o)
9omi!ing a! !he emergenc/ room es!ima!ed !o 3e 1:4 cu& in amoun! &er e&isode.
The a!!ending &h/sician ga9e !he )ollo$ing im&ressions<
1. T-cell "cu!e ./m&hoc/!ic .eu0emia
2. %as!roeso&hageal =e)lu> #isease
8. =:* "cu!e -ancrea!i!is
1
FAMILY HISTORY
III. PHYSICAL ASSESSMENT
2
". %eneral "&&earance and ?eha9ior
-a!ien! a&&eared !o 3e conscious, coheren!, res&onsi9e and $ell orien!ed o) her &resen!
condi!ion. "! !imes, she ma/ 3ecome irri!a3le and unin!eres!ed due !o &ain )el!. The &a!ien!@s
9i!al signs are !he )ollo$ing< !em&era!ure o) 8A.7
'
, &ulse ra!e o) 8' 3ea!s &er minu!e,
res&ira!or/ ra!e o) 24 3rea!hs &er minu!e and 3lood &ressure o) 1'':7' mmhg.
;&on recei9ing !he &a!ien!, she $as &ale-loo0ing, 3ald, $hich is a side e))ec! o)
chemo!hera&/, ec!omor&hic $i!h 3od/ malaise and has guarding 3eha9ior a! e&igas!ric area o)
!he a3domen. Facial grimacing $as &resen! due !o &ain. She re&or!ed a &ain score o) 5:1'. She
has a ches! !horaco!om/ !u3e in !he righ! lung $hich $as a!!ached !o a leg 3ag.
?. S0in
The s0in is uni)orml/ 3ro$n in color 3u! &ale in all areas and &ar!s o) !he 3od/. 5o$e9er,
ecch/mosis $as no!ed a! !he an!ecu3i!al )ossa due !o )reBuen! e>!rac!ion o) 3lood. S0in is dr/,
$arm !o !ouch, and )ree )rom an/ o!her lesions or a3rasions. C>ce&! )or !he si!e o) !he ches!
!u3e !horaco!om/, o!her areas o) !he 3od/ has in!ac! s0in. The )ace has non-&i!!ing edema
secondar/ !o allergic reac!ions !o medica!ions. Signi)ican! o!her 9er3ali4ed !ha! !his $as no! her
original s0in color. The &a!ien! used !o ha9e ligh!er com&le>ion 3e)ore undergoing
chemo!hera&/.
. 5ead and Face
The s0ull is normoce&halic and s/mme!rical. 6! is aligned $i!h !he 3od/ and no lesions,
nodules and masses no!ed. Facial )ea!ures $ere edema!ous 3u! )acial mo9emen!s $ere
s/mme!rical.
#. C/es and 2ision
The e/e3ro$s are 9er/ !hin and s/mme!ricall/ aligned $i!h eBual mo9emen!. C/elids are
in!ac! and closes s/mme!ricall/. Sclera a&&ears $hi!e $i!hou! lesions. -al&e3ral conDunc!i9a
$as shin/, smoo!h and &ale &in0 in color. There $as no e9idence o) !enderness or s$elling o9er
!he lacrimal gland. ornea $as !rans&aren!, $i!h de!ails o) !he iris 9isi3le. -u&ils are 3lac0 in
color, eBual in si4e a! 2mm and rounded, reac!i9e !o ligh! and accommoda!ion.
C. Car and 5earing
Cars are s/mme!rical !o each o!her, )ree )rom lesions and unusual discharges. -a!ien! is
a3le !o res&ond $hen as0ed a! 3o!h near and )ar dis!ance.
F. Nose and Sinuses
C>!ernal nares are s/mme!rical. 6! is a! !he cen!er o) !he )ace, non-!ender and has no
lesions or unusual discharges o3ser9ed. Nasal se&!um is in!ac! and in midline. -a!ien! has no
di))icul!/ di))eren!ia!ing and iden!i)/ing smells.
%. Mou!h and *ro&har/n>
.i&s a&&ear &ale and dr/. Tongue is mois! and )ree )rom lesions. -a!ien! has com&le!e se!
3
o) !ee!h $i!hou! 9eneers or den!ures. %ag re)le> is &resen!.
5. Nec0
Nec0 is in midline and is aligned $i!h !he 3od/. 6! has good )le>ion, e>!ension and !urning o)
head.
6. =es&ira!or/ S/s!em
hes! is s/mme!rical, $i!h !he ches! !u3e a! righ! ches! $all. =es&ira!ions are dee& and
dia&hragma!ic. =egulari!/ are al!ered $hen in &ain. ?rea!h sounds are clear and !here $as no
cough no!ed.
1. ardio9ascular S/s!em
"&ical &ulse is regular and audi3le in all 4 ana!omical si!es, no a3normal hear! sounds
heard u&on auscul!a!ion. There is no Dugular 9ein dis!en!ion no!ed.
E. -eri&heral 2ascular S/s!em
-ulse ra!e is regular and s!rong on 3o!h u&&er and lo$er e>!remi!ies. No sus&ec!ed 3ulging
9ein on legs and cal9es o3ser9ed. .im3s are no! !ender u&on &al&a!ion. a&illar/ re)ill is 2
seconds. There is nega!i9e 5oman@s Sign and claudica!ion no!ed. Nails are normal.
.. ?reas!s and ">illae
-a!ien! re&or!ed non-!enderness o) 3o!h 3reas!s. No a3normal discharges no!ed. 5o$e9er,
a scar is no!ed a! !he medias!inum a))ec!ing some &ar! o) !he 3reas!s due !o !he &resence o)
mon!hs ago.
M. "3domen: %as!roin!es!inal S/s!em
-a!ien! 9er3ali4ed &ain on e&igas!ric area and loss o) a&&e!i!e. "3dominal s0in is in!ac! and
has normoac!i9e 3o$el mo9emen!s. -a!ien! 9er3ali4ed no di))icul!/ in de)eca!ing, has regular
3o$el mo9emen! and usuall/ de)eca!es once a da/ or e9er/ o!her da/. S!ool is so)! and 3ro$n
in color.
N. Musculos0ele!al S/s!em
?o!h u&&er and lo$er e>!remi!ies are &osi!i9e !o )le>ion and e>!ension. %ras& is s!rong on
3o!h hands. S!reng!h o) e>!remi!ies are eBuall/ s!rong. There are no cre&i!a!ions heard u&on
mo9emen! and de)ormi!ies o3ser9ed.
*. =e&roduc!i9e S/s!em
-a!ien! 9er3ali4ed no s$elling and !enderness on inguinal area. There are no unusual
9aginal discharges no!ed.
-. ;rinar/ S/s!em
-a!ien! re&or!ed no &ain u&on urina!ing. ;rine is am3er /ello$ !o dar0 /ello$ in color.
4
F. -s/choemo!ional "s&ec!
-a!ien! has a 9er/ su&&or!i9e )amil/ and sho$s a))ec!ion !o !he &a!ien!. She !ends !o 3e
irri!a3le and aloo) a! !imes and usuall/ &re)ers !o 3e alone. ?u! she is o&en !o discuss ma!!ers
regarding her condi!ion !o her &aren!s and si3lings. She is a regis!ered nurse $ho &re9iousl/
$or0ed as a call cen!er agen!. 5er mo!her 9er3ali4ed !ha! her )riends are also 9er/ su&&or!i9e
and a))ec!iona!e !o her increasing !he &a!ien!@s sense o) sel)-es!eem and &osi!i9i!/.
=. S&iri!ual
-a!ien! a!!ends masses e9er/ Sunda/ and during s&ecial occasions. She s&on!aneousl/
&ra/s e9er/ nigh! 3e)ore she slee&s and and e9er/ morning she $a0es u&. She also&ra/s !he
rosar/ $i!h her )amil/.
IV. ANATOMY AND PHYSIOLOGY
CIRCULATORY SYSTEM
Blood is a 3odil/ )luid !ha! deli9ers necessar/ su3s!ances such as nu!rien!s and o>/gen
!o !he cells and !rans&or!s me!a3olic $as!e &roduc!s a$a/ )rom !hose same cells. ?lood is made
u& o) liBuid +called &lasma, and solid cells. The 3one marro$ is !he so)!, s&ong/ su3s!ance in
!he cen!er o) !he 3one $here 3lood cells are made.
Fig.1 Bone Marrow
Strutur!
"ll our 3lood cells de9elo& )rom s!em cells. The &rocess o) 3lood cell de9elo&men! is
called hema!o&oiesis. 6n !he earlies! s!age o) 3lood cell de9elo&men!, s!em cells 3egin !o
5
de9elo& ei!her along !he l/m&hoid cell line or !he m/eloid cell line. The 3las!s ma!ure in!o 8
!/&es o) 3lood cells, called red 3loods cells, &la!ele!s and $hi!e 3lood cells.
Fig.2 Development of Blood Cells
Fu"t#o"
The main )unc!ion o) 3lood is !o su&&l/ nu!rien!s !o and remo9e $as!e )rom cells,
!rans&or! hormones !o !issues and &ro!ec! !he 3od/ )rom harm)ul microorganisms. Cach !/&e o)
3lood cell has a s&eci)ic Do3.
Blood !rans&or!s gases, namel/ o>/gen +*2, and car3on dio>ide +*2,, 3e!$een !he
lungs and res! o) !he 3od/, nu!rien!s )rom !he diges!i9e !rac! and s!orage si!es !o !he res! o) !he
3od/, $as!e &roduc!s !o 3e de!o>i)ied or remo9ed 3/ !he li9er and 0idne/s, hormones )rom !he
glands in $hich !he/ are &roduced !o !heir !arge! cells, hea! !o !he s0in so as !o hel& regula!e
3od/ !em&era!ure
R!d $lood !ll% carr/ o>/gen )rom !he lungs !o !he res! o) !he 3od/ and re!urn car3on
dio>ide !o !he lungs. The/ are also called !r&t'ro&t!% and !he/ are !he mos! common !/&e
o) 3lood cell and !he 9er!e3ra!e organismGs &rinci&al means o) deli9ering o>/gen +*2, !o !he
3od/ !issuesH9ia 3lood )lo$ !hrough !he circula!or/ s/s!em. =?s !a0e u& o>/gen in
!he lungs or gills and release i! in!o !issues $hile sBuee4ing !hrough !he 3od/Gs ca&illaries.
Pl(t!l!t% also called I!hrom3oc/!esI, are 3lood cells $hose )unc!ion +along $i!h
!he coagula!ion )ac!ors, is !o s!o& 3leeding. -la!ele!s ha9e no nucleus< !he/ are )ragmen!s o)
c/!o&lasm $hich are deri9ed )rom !he mega0ar/oc/!es o) !he 3one marro$, and !hen en!er !he
circula!ion. These unac!i9a!ed &la!ele!s are 3icon9e> discoid s!ruc!ures sha&ed li0e a lens, 2J
8 Km in grea!es! diame!er. -la!ele!s are )ound onl/ in mammals, an ada&!a!ion !ha! ma/ ha9e
e9ol9ed !o o))se! !he ris0 o) dea!h )rom hemorrhage a! child3ir!h J a ris0 uniBue !o mammals.
6
)'#t! $lood !ll% also called l!u*o&t!% or l!uo&t!%, are !he cells o) !he immune
s/s!em !ha! are in9ol9ed in de)ending !he 3od/ agains! 3o!h in)ec!ious disease and )oreign
in9aders. Fi9e di))eren! and di9erse !/&es o) leu0oc/!es e>is!, and se9eral !/&es
+including monoc/!es and neu!ro&hils, are &hagoc/!ic. "ll leu0oc/!es are &roduced and deri9ed
)rom a mul!i&o!en! cell in !he 3one marro$ 0no$n as a hema!o&oie!ic s!em cell. The/ li9e )or
a3ou! !hree !o )our da/s in !he a9erage human 3od/. .eu0oc/!es are )ound !hroughou! !he 3od/,
including !he 3lood and l/m&ha!ic s/s!em.
T&+!% o, )'#t! Blood C!ll%
Gr("ulo&t!% -,ro. t'! .&!lo#d !ll l#"!/ are ca!egor/ o) $hi!e 3lood
cells charac!eri4ed 3/ !he &resence o) granules in !heir c/!o&lasm. The/ are also
called +ol&.or+'o"ul!(r l!u*o&t!% +PMN, PML, orPMNL, 3ecause o) !he 9ar/ing sha&es
o) !he nucleus, $hich is usuall/ lo3ed in!o !hree segmen!s. This dis!inguishes !hem )rom !he
mononuclear agranuloc/!es. 6n common &arlance, !he !erm polymorphonuclear leukocyte o)!en
re)ers s&eci)icall/ !o neu!ro&hil granuloc/!es !he mos! a3undan! o) !he granuloc/!esL !he o!her
!/&es +eosino&hils, 3aso&hils, and mas! cells, ha9e lo$er num3ers. %ranuloc/!es are &roduced
9ia granulo&oiesis in !he 3one marro$. %ranuloc/!es des!ro/ 3ac!eria !o )igh! in)ec!ion.
N!utro+'#l% are )ormed )rom s!em cells in !he 3one marro$. The/ are shor!-li9ed and
highl/ mo!ile. Neu!ro&hils are a !/&e o) &hagoc/!e and are normall/ )ound in !he 3loods!ream.
#uring !he 3eginning +acu!e, &hase o) in)lamma!ion, &ar!icularl/ as a resul! o) 3ac!erial in)ec!ion,
en9ironmen!al e>&osure, and some cancers, neu!ro&hils are one o) !he )irs!-res&onders o)
in)lamma!or/ cells !o migra!e !o$ards !he si!e o) in)lamma!ion.
Eo%#"o+'#l% are $hi!e 3lood cells and one o) !he immune s/s!em com&onen!s
res&onsi3le )or com3a!ing mul!icellular &arasi!es and cer!ain in)ec!ions in 9er!e3ra!es. "long
$i!h mas! cells, !he/ also con!rol mechanisms associa!ed $i!h allerg/ and as!hma. The/
are granuloc/!es !ha! de9elo& during hema!o&oiesis in !he 3one marro$ 3e)ore migra!ing in!o
3lood.
B(%o+'#l% are !he leas! common o) !he granuloc/!es, ?aso&hils a&&ear in man/
s&eci)ic 0inds o) in)lamma!or/ reac!ions, &ar!icularl/ !hose !ha! cause allergic s/m&!oms.
?aso&hils con!ain an!icoagulan! he&arin, $hich &re9en!s 3lood )rom clo!!ing !oo Buic0l/. The/
also con!ain !he 9asodila!or his!amine, $hich &romo!es 3lood )lo$ !o !issues. The/ can 3e )ound
in unusuall/ high num3ers a! si!es o) ec!o&arasi!e in)ec!ion, e.g.,!ic0s.
Mo"o&t!% -,ro. t'! .&!lo#d !ll l#"!/ are !he larges! o) all leu0oc/!es. Monoc/!es
ha9e 3ean-sha&ed nuclei !ha! are unilo3ar, $hich ma0es !hem one o) !he !/&es o) mononuclear
leu0oc/!es +agranuloc/!es,. The/ &la/ mul!i&le roles in immune )unc!ion. Such roles include< +1,
re&lenishing residen! macro&hages under normal s!a!es, and +2, in res&onse !o in)lamma!ion
signals, monoc/!es can mo9e Buic0l/ +a&&ro>. 8J12 hours, !o si!es o) in)ec!ion in !he !issues
and di9ide:di))eren!ia!e in!o macro&hages and dendri!ic cells !o elici! an immune res&onse. 5al)
o) !hem are s!ored in !he s&leen
L&.+'o&t!% -,ro. l&.+'o#d !ll l#"!/ are an/ o) !hree !/&es o) $hi!e 3lood cell in
a 9er!e3ra!eGs immune s/s!em. "ll !hree are agranuloc/!es. The/ include na!ural 0iller cells +NE
cells,,, T cells +)or cell-media!ed, c/!o!o>ic ada&!i9e immuni!/,, and ? cells +)or humoral,
an!i3od/-dri9en ada&!i9e immuni!/,. The/ are !he main !/&e o) cell )ound in l/m&h, $hich
&rom&!ed !he name lymphocyte.The &rimar/ agen!s o) !he immune res&onse are l/m&hoc/!es,
7
$hi!e 3lood cells +leu0oc/!es, !ha! origina!e in !he 3one marro$ +li0e all 3lood cells, 3u!
concen!ra!e in l/m&hoid !issues such as !he l/m&h nodes, !he !h/mus gland, and !he s&leen.
B !ll% +? l/m&hoc/!es, can 3e dis!inguished )rom o!her l/m&hoc/!es, such as T
cells and na!ural 0iller cells +NE cells,, 3/ !he &resence o) a &ro!ein on !he ? cellGs ou!er
sur)ace 0no$n as a ? cell rece&!or. This s&eciali4ed rece&!or &ro!ein allo$s a ? cell !o 3ind !o
a s&eci)ic an!igen. The &rinci&al )unc!ions o) ? cells are !o ma0e an!i3odies agains! an!igens, !o
&er)orm !he role o) an!igen-&resen!ing cells +"-s,, and !o de9elo& in!o memor/ ? cells a)!er
ac!i9a!ion 3/ an!igen in!erac!ion. ? cells also release c/!o0ines +&ro!eins,, $hich are used )or
signaling immune regula!or/ )unc!ions.
T !ll% are a !/&e o) l/m&hoc/!e +i!sel) a !/&e o) $hi!e 3lood cell, !ha! &la/ a cen!ral role
in cell-media!ed immuni!/. The/ can 3e dis!inguished )rom o!her l/m&hoc/!es, such as ?
cells and na!ural 0iller cells +NE cells,, 3/ !he &resence o) a Tcell receptor +T=, on !he cell
sur)ace. The/ are called T cells 3ecause !he/ ma!ure in !he !h/mus +al!hough some also ma!ure
in !he !onsils,
Cytoto!ic T cells +0iller T cells, are ac!i9a!ed $hen !he/ recogni4e an!igens !ha! are
mi>ed $i!h !he M56 &ro!eins o) sel) cells.
"elper T cells are ac!i9a!ed $hen !he/ recogni4e an!igens !ha! are mi>ed $i!h !he M5
66 &ro!eins o) sel) cells.
#uppressor T cells are 3elie9ed !o 3e in9ol9ed in $inding do$n a success)ul immune
res&onse and in &re9en!ing !he a!!achmen! o) unin)ec!ed sel) cells.
Memory T cells are longli9ed cells &ossessing !he same an!igen rece&!ors as !heir
&aren! T cell.
T'! L&.+'(t# S&%t!.
T'! L&.+'(t# S&%t!. is &ar! o) !he circula!or/ s/s!em, com&rising a ne!$or0
o) l/m&ha!ic 9essels !ha! carr/ a clear )luid called l/m&h direc!ionall/ !o$ards !he hear!. The
o!her main )unc!ion is !ha! o) de)ense in !he immune s/s!em. ./m&h is 9er/ similar !o 3lood
&lasma 3u! con!ains l/m&hoc/!es and o!her $hi!e 3lood cells. 6! also con!ains $as!e &roduc!s
and de3ris o) cells !oge!her $i!h 3ac!eria and &ro!ein. "ssocia!ed organs com&osed
o) l&.+'o#d t#%%u! are !he si!es o) l/m&hoc/!e &roduc!ion.
Fu"t#o":
The main )unc!ion o) !he l/m&ha!ic s/s!em is !o collec! and !rans&or! !issue )luids )rom
!he in!ercellular s&aces in all !he !issues o) !he 3od/, 3ac0 !o !he 9eins in !he 3lood s/s!emL i!
&la/s an im&or!an! role in re!urning &lasma &ro!eins !o !he 3loods!reamL diges!ed )a!s are
a3sor3ed and !hen !rans&or!ed )rom !he 9illi in !he small in!es!ine !o !he 3loods!ream 9ia !he
lac!eals and l/m&h 9essels. Ne$ l/m&hoc/!es are manu)ac!ured in !he l/m&h nodesL an!i3odies
and an!i +manu)ac!ures in !he l/m&h nodes, assis! !he 3od/ !o 3uild u& an e))ec!i9e immuni!/ !o
in)ec!ious diseases
8
Fig. $ The %ymphatic #ystem
L&.+' is !he )luid !ha! circula!es !hroughou! !he l/m&ha!ic s/s!em. The l/m&h is )ormed
$hen !he in!ers!i!ial )luid +!he )luid $hich lies in !he in!ers!ices o) all 3od/ !issues, is collec!ed
!hrough l/m&h ca&illaries. 6! is !hen !rans&or!ed !hrough l/m&h 9essels !o l/m&h nodes 3e)ore
em&!/ing ul!ima!el/ in!o !he righ! or !he le)! su3cla9ian 9ein, $here i! mi>es 3ac0 $i!h 3lood.
L&.+' Nod!% is an o9al-sha&ed organ o) !he l/m&ha!ic s/s!em, dis!ri3u!ed $idel/
!hroughou! !he 3od/ including !he arm&i! and s!omach and lin0ed 3/ l/m&ha!ic 9essels. ./m&h
nodes are maDor si!es o) ?, T, and o!her immuni!/ cells. ./m&h nodes are im&or!an! )or !he
&ro&er )unc!ioning o) !he immune s/s!em, ac!ing as )il!ers )or )oreign &ar!icles and cancer cells.
./m&h nodes do no! deal $i!h !o>ici!/, $hich is &rimaril/ done 3/ !he li9er and 0idne/s.
M(0or A!%%or& L&.+'(t# Or1("%
To"%#l%
The !onsils +&ala!ine !onsils, are a &air o) so)! !issue masses loca!ed a! !he rear o) !he
!hroa! +&har/n>,. Cach !onsil is com&osed o) !issue similar !o l/m&h nodes, co9ered 3/ &in0
mucosa +li0e on !he adDacen! mou!h lining. The !onsils are &ar! o) !he l/m&ha!ic s/s!em, $hich
hel&s !o )igh! in)ec!ions.
S+l!!"
The s&leen is !he larges! l/m&ha!ic organ. 6! is loca!ed in !he u&&er-le)! a3domen. The
s&leen<ma0es, s!ores and remo9es l/m&hoc/!es, )il!ers !he 3lood, s!ores red 3lood cells,
des!ro/s old red 3lood cells
9
T'&.u%
The !h/mus gland, des&i!e con!aining glandular !issue and &roducing se9eral hormones,
is much more closel/ associa!ed $i!h !he immune s/s!em !han $i!h !he endocrine s/s!em. The
!h/mus ser9es a 9i!al role in !he !raining and de9elo&men! o) T-l/m&hoc/!es or T cells, an
e>!remel/ im&or!an! !/&e o) $hi!e 3lood cell. T cells de)end !he 3od/ )rom &o!en!iall/ deadl/
&a!hogens such as 3ac!eria, 9iruses, and )ungi. The !h/mus is a so)!, roughl/ !riangular organ
loca!ed in !he medias!inum o) !he !horacic ca9i!/ an!erior and su&erior !o !he hear! and &os!erior
!o !he s!ernum.
Ad!"o#d%
The adenoids are ac!uall/ a single, small mass o) l/m&ha!ic !issue in !he 3ac0 o) !he
nose +naso&har/n>, !ha! con!ains l/m&hoc/!es. "l!hough !he/ are o)!en called adenoids !here is
onl/ one adenoid. The adenoid is also some!imes called !he &har/ngeal !onsil.
Bo"! .(rro2
The 3one marro$ is a )le>i3le !issue in !he in!erior o) 3ones. 6n humans, red 3lood
cells are &roduced 3/ cores o) 3one marro$ in !he heads o) long 3ones in a &rocess 0no$n
as hema!o&oiesis. 6! is also a 0e/ com&onen! o) !he l/m&ha!ic s/s!em, &roducing
!he l/m&hoc/!es !ha! su&&or! !he 3od/Gs immune s/s!em.
RESPIRATORY SYSTEM
T'! Pl!ur( are dou3le-la/ered serous mem3ranes !ha! surround each lung. "!!ached !o
!he $all o) !he !horacic ca9i!/, +(r#!t(l +l!ur( lines !he !horacic $all, co9ers !he su&erior sur)ace
o) !he dia&hragm and se&ara!es !he &leural ca9i!/ )rom !he medias!inum. The cos!al &or!ion o)
!he &arie!al &leura lines !he inner as&ec! o) !he ri3s and in!er9ening in!ercos!al muscles, 3eing
se&ara!ed )rom !hem 3/ endo!horacic )ascia. The 3#%!r(l +l!ur( is a!!ached direc!l/ !o !he
lungs, as o&&osed !o !he &arie!al &leura, $hich is a!!ached !o !he o&&osing !horacic ca9i!/. The
s&ace 3e!$een !hese !$o delica!e mem3ranes is 0no$n as !he in!ra&leural s&ace +&leural
ca9i!/,. on!rac!ion o) !he dia&hragm causes a nega!i9e &ressure $i!hin !his s&ace and )orces
!he lungs !o e>&and, resul!ing in &assi9e e>hala!ion and ac!i9e inhala!ion
10
Pl!ur(l C(3#t& is 3e!$een !he &arie!al and 9isceral &leura $hich crea!es a hollo$ s&ace
)or !he lungs !o e>&and in!o during inhala!ion. Serous )luid secre!ed 3/ !he &leural mem3ranes
lu3rica!es !he inside o) !he &leural ca9i!/ !o &re9en! irri!a!ion !o !he lungs during 3rea!hing.
D#(+'r(. is !he dome-sha&ed shee! o) muscle and !endon !ha! ser9es as !he main
muscle o) res&ira!ion and &la/s a 9i!al role in !he 3rea!hing &rocess. "lso 0no$n as !he !horacic
dia&hragm, i! ser9es as an im&or!an! ana!omical landmar0 !ha! se&ara!es !he !hora>, or ches!,
)rom !he a3domen. The origins o) !he dia&hragm are )ound along !he lum3ar 9er!e3rae o) !he
s&ine and !he in)erior 3order o) !he ri3s and s!ernum. *&enings in !he dia&hragm allo$ !he
eso&hagus, &hrenic and 9agus ner9es, descending aor!a, and in)erior 9ena ca9a !o &ass
3e!$een !he !horacic and a3dominal ca9i!ies.
Bro"'#ol!% are made o) elas!in )i3ers and smoo!h muscle !issue. The !issue o) !he
3ronchiole $alls allo$s !he diame!er o) 3ronchioles !o change !o a signi)ican! degree. When !he
3od/ reBuires grea!er 9olumes o) air en!ering !he lungs, such as during e>ercise, !he
3ronchioles dila!e !o &ermi! grea!er air)lo$. 6n res&onse !o dus! or o!her en9ironmen!al
&ollu!an!s, !he 3ronchioles can cons!ric! !o &re9en! !he &ollu!ion o) !he lungs.
Al3!ol#4 )ound in !he lung &arench/ma, !he &ulmonar/ al9eoli are !he !erminal ends o)
!he res&ira!or/ !ree, $hich ou!cro& )rom ei!her al9eolar sacs or al9eolar duc!s, $hich are 3o!h
si!es o) gas e>change $i!h !he 3lood as $ell. "l9eoli are !he )unc!ional uni!s o) !he lungs !ha!
&ermi! gas e>change 3e!$een !he air in !he lungs and !he 3lood in !he ca&illaries o) !he lungs.
Cach al9eolus is a hollo$, cu&-sha&ed ca9i!/ surrounded 3/ man/ !in/ ca&illaries.
GASTROINTESTINAL SYSTEM
Fig.& 'astrointestinal #ystem
E%o+'(1u% is one o) !he u&&er &ar!s o) !he gas!roin!es!inal s/s!em. "! !he mou!h
o&ening, i! is con!inuous $i!h !he 3ac0 o) !he oral ca9i!/, &assing do$n$ards !hrough !he rear
&ar! o) !he medias!inum , !hrough !he dia&hragm, and in!o !he s!omach.
Lo2!r E%o+'(1!(l S+'#"t!r -LES/ is a 3undle o) muscles a! !he lo$ end o) !he
eso&hagus, $here i! mee!s !he s!omach. When !he .CS is closed, i! &re9en!s acid and s!omach
con!en!s )rom !ra9eling 3ac0$ards )rom !he s!omach. The .CS muscles are no! under 9olun!ar/
con!rol.
11
V. CASE DISCUSSION
5andling di))eren! cases hel&ed us !o ha9e an idea on $ha! $ill 3e our &riori!/ care and
a! !he same !ime, di))eren!ia!e $ha! nursing care $ill 3e done !o a s&eci)ic case. We ha9e
chosen "cu!e ./m&hoc/!ic .eu0emia +".., 3ecause an increasing a!!en!ion has 3een &aid !o
&a!ien!s $ho $ere diagnosed $i!h !his case. ".. is a disease !ha! ma/ occur a! an/ s!ages o)
one@s li)e 3u!, i! is !he mos! common !/&e o) leu0emia in children and /oung adul!s /ounger !han
2' /ears. -a!ien!s $i!h ".. need su&&or!i9e care &h/sicall/, emo!ionall/, s&iri!uall/ and
&s/chologicall/.
"cu!e l/m&hoc/!ic leu0emia +".., is a !/&e o) cancer o) !he 3lood and 3one marro$ H
!he s&ong/ !issue inside 3ones $here 3lood cells are made.The $ord Iacu!eI in acu!e
l/m&hoc/!ic leu0emia comes )rom !he )ac! !ha! !he disease &rogresses ra&idl/ and crea!es
imma!ure 3lood cells, ra!her !han ma!ure ones. The Il/m&hoc/!icI in acu!e l/m&hoc/!ic leu0emia
re)ers !o !he $hi!e 3lood cells called l/m&hoc/!es, $hich ".. a))ec!s. "cu!e l/m&hoc/!ic
leu0emia is also 0no$n as acu!e l/m&ho3las!ic leu0emia.
".. is di9ided in!o !$o maDor su3!/&es 3ased on !he &h/sical charac!eris!ics and !he
le9el o) de9elo&men! o) !he leu0emia cells. This 3asic classi)ica!ion hel&s !he !rea!men! !eam !o
s!ar! &lanning !he 3es! course o) !rea!men! )or !he &a!ien!. The &rinci&al ".. su3!/&es are ?-cell
acu!e l/m&hoc/!ic leu0emia and T-cell acu!e l/m&hoc/!ic leu0emia.
T-cell acu!e l/m&hoc/!ic leu0emias is a rare !/&e o) leu0emia. There are no s&eci)ic
s/m&!oms o) T-cell acu!e l/m&hoc/!ic leu0emia and !he condi!ion can 3e )ocused $i!h o!her
common illnesses. 6n general, T-cell acu!e l/m&hoc/!ic leu0emia de9elo&s 9er/ Buic0l/ and !he
s/m&!oms a&&ear o9er a ma!!er o) da/s or $ee0s. 6! is also no! an inheri!ed condi!ion !ha! can
3e &assed do$n !hrough )amilies.
The "merican ancer Socie!/@s es!ima!es )or acu!e l/m&hoc/!ic leu0emia +".., in !he
;ni!ed S!a!es )or 2'14 +including 3o!h children and adul!s, are<
M "3ou! A,'2' ne$ cases o) ".. +8,14' in males and 2,88' in )emales,
M "3ou! 1,44' dea!hs )rom ".. +81' in males and A8' in )emales,
The a9erage &erson@s li)e!ime ris0 o) ge!!ing ".. is less !han 1 in 75'. The ris0 is sligh!l/
higher in males !han in )emales, and higher in $hi!es !han in ")rican "mericans.
Mos! cases o) ".. occur in children, 3u! mos! dea!hs )rom ".. +a3ou! 4 ou! o) 5, occur
in adul!s. hildren ma/ do 3e!!er 3ecause o) di))erences in childhood and adul! ".. in !he
disease i!sel), di))erences in !rea!men! +children@s 3odies can o)!en handle aggressi9e !rea!men!
3e!!er !han adul!@s,, or some com3ina!ion o) !hese.
The -hili&&ine ancer Socie!/, 6nc. 2'1' &u3lished a s!ud/ a3ou! !he di))eren! !/&es o)
cancer in !he -hili&&ines. .eu0emia $as one o) !he !o& 1' cancer cases o) 3o!h se>es $i!h
es!ima!ed !o!al o) 8158 ne$ cases. There $ere 1484 es!ima!ed ne$ cases o) leu0emia !ha!
ran0ed as 8
!h
leading cause o) mor3idi!/ among $omen and es!ima!ed cancer dea!hs o) 1228 in
!he -hili&&ines !ha! ran0ed A
!h
among !he !o& 1' mor!ali!/ ra!es.
12
OB5ECTIVES:
Nurse-cen!ered<
;&on com&le!ion o) !his case s!ud/, !he nurses $ill 3e a3le !o<
6den!i)/ causa!i9e )ac!ors o) !he occurrence o) !he disease
C>&lain !he &a!ho&h/siolog/ o) !he clien!@s condi!ion
Formula!e signi)ican! nursing diagnoses $i!h !he a&&ro&ria!e nursing care &lans
regarding !he disease and i!s com&lica!ions
;!ili4e !$o nursing !heories )i! !o !he case o) !he &a!ien! un!o !he said nursing care &lans
"&&l/ e))ec!i9e nursing in!er9en!ions !ha! $ill 3e &ro9en use)ul )or !he clien!
Eno$ !he medical and surgical managemen! o) !his s&eci)ic case
-a!ien!-cen!ered<
;&on !he com&le!ion o) !his case s!ud/, clien! $ill 3e a3le !o<
;nders!and !he disease &rocess
Eno$ !he di))eren! medical regimen and !heir &ur&oses
#emons!ra!e $illingness in coordina!ion $i!h heal!hcare main!enance
.earn ho$ !o &re9en! com&lica!ions o) !he disease !hrough li)e s!/le modi)ica!ions and
diligen!l/ com&l/ing !o medica!ion and !hera&/ regimen.
IDEAL AND ACTUAL MEDICAL6SURGICAL MANAGEMENT
IDEAL
Trea!men! o) &a!ien!s $i!h acu!e l/m&hoc/!ic leu0emia de&ends on age o) &a!ien!. 6n
general, !rea!men! )alls in!o !$o &hases<
M (emission induction therapy. The &ur&ose o) !he )irs! &hase o) !rea!men! is !o 0ill !he
leu0emia cells in !he 3lood and 3one marro$. 5o$e9er, remission induc!ion usuall/ doesnG!
$i&e ou! all o) !he leu0emia cells, so one needs )ur!her !rea!men! !o &re9en! !he disease )rom
re!urning.
M Consolidation therapy. "lso called &os!-remission !hera&/, main!enance !hera&/ or
in!ensi)ica!ion, !his &hase o) !rea!men! is aimed a! des!ro/ing !he remaining leu0emia cells. 6!Gs
considered crucial !o decreasing !he ris0 o) rela&se.
Thera&ies used in !hese &hases include<
M Chemotherapy. hemo!hera&/ is !he maDor )orm o) remission induc!ion !hera&/. "
common course o) !hera&/ in9ol9es !$o chemo!hera&/ drugs H c/!ara3ine +/!osar-;,,
)ollo$ed 3/ an an!hrac/cline drug, such as daunoru3icin +eru3idine, or idaru3icin
+6dam/cin,. " !hird medica!ion, !hioguanine, is some!imes used. This chemo!hera&/ can cause
anemia, in)ec!ion and 3leeding. 6) !he )irs! c/cle o) !rea!men! doesn@! cause remission, one ma/
need i! re&ea!ed one or !$o more !imes.
13
*!her drug com3ina!ions also ma/ 3e used, de&ending on !he s&eci)ic si!ua!ion.
hemo!hera&/ can also 3e used )or consolida!ion !hera&/. This &hase ma/ include a
com3ina!ion o) di))eren! medica!ions !ha! mimic !he induc!ion, 3u! usuall/ includes high doses o)
c/!ara3ine 3/ i!sel) )or one !o !hree c/cles. The doc!or ma/ also &rescri3e medica!ions !ha!
3oos! $hi!e cell &roduc!ion !o reduce !he ris0 o) in)ec!ion. These medica!ions are called
granuloc/!e colon/ s!imula!ing )ac!ors +Neu&ogen, .eu0ine,.
M )ther drug therapy. "rsenic !rio>ide and all-!rans re!inoic acid +"T=", are an!i-cancer
drugs !ha! can 3e used alone H or in com3ina!ion $i!h chemo!hera&/ H )or remission
induc!ion o) cer!ain leu0emias. These drugs cause leu0emia cells $i!h a s&eci)ic gene mu!a!ion
!o ma!ure and die, or !o s!o& di9iding.
M Biological therapy. "lso 0no$n as immuno!hera&/, 3iological !hera&/ uses su3s!ances
!ha! 3ols!er !he immune s/s!em@s res&onse !o cancer.
Monoclonal an!i3odies are one )orm o) 3iological !hera&/. These an!i3odies are
&roduced in a la3ora!or/, 3u! !he/ mimic &ro!ein &roduc!s )ound in !he immune s/s!em
+an!i3odies, !ha! a!!ac0 )oreign su3s!ances +an!igens, on leu0emic cells.
M Bone marrow transplant. This is ano!her o&!ion )or consolida!ion !hera&/ )or &eo&le a!
high ris0 o) rela&se or )or !rea!ing rela&se $hen i! occurs. This &rocedure allo$s someone $i!h
leu0emia !o re-es!a3lish heal!h/ s!em cells 3/ re&lacing !heir leu0emic 3one marro$ $i!h
leu0emia-)ree marro$. 6) one chooses !his !rea!men!, heGll recei9e 9er/ high doses o)
chemo!hera&/ or radia!ion !hera&/ !o des!ro/ his leu0emia-&roducing 3one marro$. This
marro$ is !hen re&laced 3/ 3one marro$ )rom a com&a!i3le donor +allogeneic !rans&lan!,. 6n
some cases, he ma/ also 3e a3le !o use his o$n 3one marro$ )or !rans&lan! +au!ologous
!rans&lan!,. This is &ossi3le i) he goes in!o remission and !hen sa9e heal!h/ 3one marro$ )or a
)u!ure !rans&lan!.
M #tem cell transplant. S!em cell !rans&lan! is also used )or consolida!ion !hera&/. 6!Gs
similar !o 3one marro$ !rans&lan! e>ce&! !he s!em cells are collec!ed )rom circula!ing 3lood
+&eri&heral 3lood,, ra!her !han )rom !he 3one marro$, !han0s !o a medica!ion !ha! causes larger
num3ers o) s!em cells !o 3e released )rom !he 3one marro$. The cells used )or !rans&lan! can
3e his o$n heal!h/ cells, or !he/ can 3e collec!ed )rom a com&a!i3le donor.
This &rocedure is used more )reBuen!l/ !han 3one marro$ !rans&lan! 3ecause o)
shor!ened reco9er/ !imes and &ossi3le decreased ris0 o) leu0emia recurrence.
M (adiation Therapy. =adia!ion !hera&/ in9ol9es !he use o) radia!ion !o 0ill cancer cells
and shrin0 !umors. 6n e>!ernal radia!ion !hera&/, radia!ion is direc!ed a! !he !umor )rom a source
ou!side !he 3od/. This !/&e o) !rea!men! is used )or ".. has s&readHor ma/ s&readH!o !he
3rain and s&inal cord. 6! can also 3e used !o !rea! 3one &ain !ha! comes )rom 3one a))ec!ed 3/
!he leu0emia.
ACTUAL
14
The &a!ien! under$en! radia!ion !hera&/ )or her medias!inal l/m&homa and se9en c/cles
o) chemo!hera&/ since Fe3ruar/ 2'14 un!il no$. hemo!hera&eu!ic drugs used $ere .anase,
2incris!ine and /!ara3ine. She also had 3lood !rans)usions o) )i9e uni!s o) &ac0ed red 3lood
cells and )our uni!s o) a&heresis &la!ele! concen!ra!es. "&heresis &la!ele!s are collec!ed )rom a
single donor and are eBui9alen! !o N4-A &ooled uni!s. "n a&heresis &la!ele! concen!ra!e con!ains
2''-4''m. o) &lasma. The/ ma/ 3e collec!ed as a random uni! +random a&heresis &la!ele!s, or
3e o3!ained )or a s&eci)ic reci&ien! )rom a )amil/ mem3er or a 9olun!eer 5." com&a!i3le
Odirec!edP donor.
While admi!!ed, 62 )luid inser!ion $as done as means )or her medica!ions. ;&on
assessmen!, she had a &lain normal saline solu!ion in)using $ell a! her righ! me!acar&al 9ein
$i!h a &rescri3ed )lo$ ra!e o) 2' g!!s:min.
15