NURSING PROCESS ON LEUKEMIA

1. Personal History
1.1 Patients Profile
Name: Mr. Ajay Chaturvedi
Age: 50 years old
Sex: Male
Civil Status: Married
Religion: Roman Catholic
Date of Admission: February 04, 2014
Room No. : 532
Complaints: tonsillitis
Diagnosis: Acute Myelogenous Leukemia
1.2Family and individual information, social and health history
Mr. Ajay, 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. Ajay is not hypertensive, diabetic and asthmatic. He is an occasional
drinker and a positive smoker which he consumes one pack per day. Mr. Ajay 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 self-esteem, 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.
 PHYSICAL ASSESSMENT

Body Parts Inspection Palpation Percussion Auscultation

HEAD Round in shape No tenderness

Normocepahlic No Lumps

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

SCALP No dandruff No Lumps noted

FACE Presence of
pimples noted,
No wrinkles,
brown in color

FOREHEAD Round, brown in No Lumps noted

color, No
wrinkles,
pimples noted

EYEBROWS Black in color, No Lumps noted

no lesions noted

EYELIDS Closes and opens No Mass noted

without difficulty

EYELASHES Equally
distributed

CONJUNCTIVA Pale, moist

SCLERA Opaque in color,

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, No mass noted

symmetrical

MOUTH Gums are pale, No mass noted

fair in size, dry

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
EARS Symmetrical, ear
wax noted, can
hear clearly,
auricle aligned
with outer
canthus

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

CHEST Equal chest Vibration felt

expansion upon tactile
RR: 24 breaths fermitus
per minute

HEART
BP: 100/60
mmhg

Clear breath
LUNGS
sounds
ABDOMEN Brown in color,
Bowel sounds: 3
no abdominal
upon
 distention auscultation

LOWER: Can perform

limited ROM
exercises,
presence of
petechiae
(pinpoint like
appearance) on
his both legs
 DIAGNOSTIC EVALUATIONS

Diagnostic Test Normal Value Result Significance

Hemoglobin 14-17.5gm/dL 6.77gm/dL Decreased: Anemia

Increased:
Hematocrit 14-17.5 19.3 Erythrocytosis

WBC 4.4-11.0 174,000 Increased: Infection

Band 3% 02% Decreased:

Segmenter 56% 05% Decreased:

Basophil 0.3% -- NORMAL

Eosnophil 2.7% -- NORMAL
Lymphocyte 34% 07% Decreased: Immuno –
deficiency
4% 61% Increased: Viral
Monocyte
infections
4.5-5.9 10 12/L 1.93 10 12/L Decreased: Anemia
RBC
80-96fL 100fL Increased: Macrocytic
MCV
Anemia
Increased: : Macrocytic
MCH 27.5-33.2pg 35.1 pg
Anemia

NORMAL
MCHC 33.4-35.5% 35.0%
-- NORMAL
MPV --
-- -- NORMAL
RDW
Platelet Count 150,000-450,000/cu Decreased: Acute
27,020/cu mm
Leukemia
mm

Reticulocyte -- NORMAL
0.5-1.5%
-- NORMAL
ESR
0.00-20.00mm/h
Increased: Fever
Creatinine Serum 2.1 mg/dL
0.7-1.5mg/dL
Decreased: Diarrhea
Potassium 3.0 mmol/L
3.6-5.0mmol/L
 ALT 11-66uL 59 uL NORMAL
Sodium 137-145mmol/L 134 mmol/L Decreased: Metabolic
Acidosis

2.5-7.5mg/L 11.9 mg/L 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 Matab-ang 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.

ANATOMY & PHYSIOLOGY

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.

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 Normal cells

 ACUTE MYELOGENOUS LEUKEMIA

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 More specific signs and

 Dyspnea During the assessment, the
 Fatigue student nurse observed that
 Pale skin, mucous the patient has a pale skin,
membrane, oral mucosa, conjunctiva and
conjunctiva, nail beds nail beds. The patient also
verbalizes that he feels weak
and sometimes he had
difficulty in breathing even
doing things with no exerted
force.
Thrombocytopenia
Manifested
The patient had a low platelet
count levels (27,020cu mm)
Manifested
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 function
because of the replacement of
the malignant cells such as
occurs in leukemia, which
results in decrease production
of platelets
(p. 265 disease management
for nurse practitioner by:
Scilling)
  Bleeding One week prior to admission,
the patient experiences
hematuria and bloody stools.
The patient also has petechiae
in his surrounding skins.
Manifested
The patient was advised by his
Neutropenia physician to wear mask all the
 infection time and must eat foods that
ca boost his immune system
Manifested
The patient had fever one
week prior to his admission
 fever because of massive tonsillitis
Manifested
The patient complains of
having difficulty in swallowing
because of tonsillitis.
 tonsillitis
In acute myelogenous
leukemia, bleeding is evident
because of a decrease
circulating platelets or
impaired 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
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
(http://www.mayoclinic.com)
The symptoms of AML are
caused by low numbers of
healthy blood cells and high
numbers of leukemia cells.
White blood cells fight
infection. Low 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 are often a source
of infection; therefore a
complain of a sore throat is an
important of early indication
Spleenomegaly Not Manifested of a potential problem
Hyperplasia of the gums Not Manifested
Bone pain Not Manifested (p. 660 Davis’s NCLEX- RN
Success by: Lagerquist)
These is because of the
proliferation of leukemia cells
within organs
(p. 897 medical- surgical
nursing by: Brunner)

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
 NURSING CARE PLAN

OBJECTIVES CONTENTS METHODOL EVALUA-

OGY TION
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 1. predisposing factors in Informal

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

2. signs and symptoms of Informal

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

3. determine the
significance Informal
on wearing a 3. significance on wearing
mask all the time discussion
mask all the
 time 3.1 this is to prevent the
patient from acquiring
4. the patient will any infection
show interest 4. shows interest during the Informal
during the health teaching discussion and
health 4.1 asks questions during the utilization of
teaching 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
5. demonstrate activities
beginning 5.1 teach client on how to Scheduling
skills on cluster activities to activities and
preventing prevent fatigue example: Informal
fatigue by Monday: 7:00-7:30 discussion
clustering (eating breakfast)
scheduled 7:30 – 9:00 watching
activities 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
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.
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” 7th edition.Pearon

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]

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