Chapter I

Introduction

Objectives of the Study:

a. General objectives

To be able to gain more knowledge about leukemia especially about Acute Myelogenous Leukemia, know the difference of AML among other leukemias and learn more chemptheraphy

b. Specific objectives

To expand our knowledge about the signs and symptoms of

Acute Myelogenous Leukemia

To know the pathophysiology of Acute Myelogenous

Leukemia

To know the proper nursing management of AML by learning

the proper interventions to be rendered to patients with

Acute Myelogenous Leukemia

To know how AML is diagnosed and the important laboratory

examinations that will confirm AML

To know the nursing priorities to consider when dealing with

patients of AML especially when patient is undergoing

chemotherapy

1

DESCRIPTION OF THE CASE

Alternative names of Acute myelogenous leukemia: AML; Acute

granulocytic leukemia; Acute nonlymphocytic leukemia (ANLL); Leukemia - acute

myeloid (AML); Leukemia - acute granulocytic; Leukemia - nonlymphocytic

(ANLL) Acute myelogenous leukemia (AML), is a fast-growing cancer of the

blood and bone marrow. In AML, the bone marrow makes many unformed cells

called blasts. Blasts normally develop into white blood cells that fight infection. However, the blasts are abnormal in AML. They do not develop and

cannot fight infections. The bone marrow may also make abnormal red blood

cells and platelets. The number of abnormal cells (or leukemia cells) grows

quickly. They crowd out the normal red blood cells, white blood cells and

platelets the body

needs./http://www.cancercenter.com/acute_myelogenous_leukemia.cfm/

The word "acute" in acute myelogenous leukemia denotes the disease's

rapid progression. 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

. /http://www.mayoclinic.com/health/acute-myelogenous-leukemia/DS00548 /

Acute Myelogenous Leukemia is a trending health concern in the Nursing profession because of dangers of treatment which is the chemotherapy. According to the article, “The Truth About Chemotherapy - It Is Dangerous”, Chemotherapy can cause heart problems, destroy bile ducts,

cause bone tissue death, restrict growth, cause infertility, lower white and red cell

counts and lead to intestinal and lactose malabsorption.

 After all, and for the overwhelming majority of the cases, there is no proof

whatsoever that chemotherapy prolongs survival expectations. And this is the

2

great lie about this therapy, that there is a correlation between the reduction of

cancer and the extension of the life of the patient." (Philip Day, "Cancer: Why

we're still dying to know the

truth"). /http://www.articlesbase.com/cancer-articles/the-truth-about-

chemotherapy-it-is-dangerous-906032.html/

As implied from the article above, chemotherapy has so many dangerous effects and it as a trending health concern to the Nursing Profession. Side effects may be acute (short-term), chronic (long-term), or permanent. Side effects may cause inconvenience, discomfort, serious illness

and even death. Additionally, certain side effects may prevent doctors from

delivering the prescribed dose of chemotherapy at the specific time and schedule

of the treatment plan. Side effects from chemotherapy can include

pain, diarrhea, constipation, mouth sores, hair loss, nausea and vomiting, and

blood-related side

effects. /http://www.chemotherapy.com/side_effects/side_effects.html/

As nurses we should be knowledgeable about chemotherapy since it has

so many dangerous side effects. We should update ourselves about how could

we alleviate the pain brought about by the side effects chemotherapy.

Chemotherapy is yet controversial because some researchers believed that

chemotherapy cannot really prolong life and can cause death.

3

BACKGROUND OF THE STUDY

 Alfred-Armand-Louis-Marie Velpeau described a 63-year-old florist who developed an illness characterized by fever, weakness, urinary stones, and substantial enlargement of the liver and spleen. Velpeau noted that the blood of this patient had a consistency "like gruel", and speculated that the appearance of the blood was due to white corpuscles. In 1845, a series of patients who died with enlarged spleens and changes in the "colors and consistencies of their blood" was reported by the Edinburgh-based pathologist J.H. Bennett; he used the term "leucocythemia" to describe this pathological condition. Further advances in the understanding of acute myeloid leukemia occurred rapidly with the development of new technology. In 1877, Paul Ehrlich developed a technique of staining blood films which allowed him to describe in detail normal and abnormal white blood cells. Wilhelm Ebstein introduced the term "acute leukemia" in 1889 to differentiate rapidly progressive and fatal leukemias from the more indolent chronic leukemias .The term "myeloid" was coined by Neumann in 1869, as he was the first to recognize that white blood cells were made in the bone marrow (Greek: µυєλός, myelos = (bone) marrow) as opposed to the spleen. The technique of bone marrow examination to diagnose leukemia was first described in 1879 by Mosler. Finally, in 1900 the myeloblast, which is the malignant cell in AML, was characterized by Naegeli, who divided the leukemias into myeloid and lymphocytic. / http://en.wikipedia.org/wiki/Acute_myeloid_leukemia#History/.

Cancer is the third leading cause of morbidity and mortality in the Philippines. Leading cancer sites/types are lung, breast, cervix, liver, colon and

rectum, prostate, stomach, oral cavity, ovary and

leukemia. /http://jjco.oxfordjournals.org/content/32/suppl_1/S52.full/. Incidence rates for all types of leukemia are higher among males than among

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females. In 2010, males are expected to account for more than 57 percent of the

new cases of leukemia. The most common types of leukemia in adults are acute myelogenous leukemia (AML), with an estimated 12,330 new cases in 2010. Leukemia is one of the top 10 most frequently occurring cancers in all races or ethnicities. Leukemia incidence is highest among whites (12.9 per

100,000) and lowest among American Indians/Alaskan natives (6.5 per

100,000), Asian and Pacific Islander populations (7.2 per

100,000). /http://www.leukemia-lymphoma.org/all_page?item_id=9346/.

Some people with acute myeloid leukemia (AML) have one or more known

risk factors but most do not. The cause of their cancer remains unknown at this time. Even when a person has one or more risk factors, there is no way to

tell whether it actually caused the cancer. During the past few years, scientists

have made great progress in understanding how certain changes in DNA can

cause normal bone marrow cells to become leukemia cells. Normal human cells

grow and function based mainly on the information contained in each cell's

chromosomes. Chromosomes are long molecules of DNA in each cell. DNA is

the chemical that makes up our genes -- the instructions for how our cells

function. We resemble our parents because they are the source of our DNA. But

our genes affect more than the way we look.

/http://www.cancer.org/Cancer/LeukemiaAcuteMyeloidAML/DetailedGuide/

leukemia-acute-myeloid-myelogenous-what-causes/

There are certain risk factors for AML. Smoking is the only proven

lifestyle-related risk factor for AML. Many people know that smoking is linked to

cancers of the lungs, mouth, throat, and larynx (voice box), but few realize that it

can also affect cells that don't come into direct contact with smoke. Cancer-

causing substances in tobacco smoke are absorbed by the lungs and spread

through the bloodstream to many parts of the body. The risk of AML may be

increased by exposure to certain chemicals. Long-term exposure to high levels

5

of benzene is a risk factor for AML. Benzene is a solvent used in the rubber

industry, oil refineries, chemical plants, shoe manufacturing, and gasoline related

industries, and is also present in cigarette smoke, and some glues, cleaning

products, detergents, art supplies, and paint strippers. Radiation exposure , High-dose radiation exposure (such as being a survivor of an atomic bomb blast

or nuclear reactor accident) increases the risk of developing AML. Japanese

atomic bomb survivors had a greatly increased risk of developing acute

leukemia, usually within 6 to 8 years after exposure. Patients with certain blood disorders seem to be at increased risk for getting AML. These include

chronic myeloproliferative disorders such as polycythemia vera, essential

thrombocytopenia, and idiopathic myelofibrosis. Chronic myelogenous leukemia

(CML) is another type of myeloproliferative disorder, and some patients with CML

later develop a form of AML. The risk of developing AML is increased further if

treatment for these disorders includes some types of chemotherapy or radiation.

Congenital syndromes (present at birth) For the most part, acute myeloid

leukemia does not appear to be an inherited disease. It is rare for it to run in

families, so a person's risk is not usually increased if a family member has the

disease. But there are some congenital syndromes with genetic changes that

seem to raise the risk of AML. These include; Down syndrome, Fanconi-anemia

Bloom syndrome, Ataxia-telangiectasia, and Blackfan-Diamond syndrome.

Having an identical twin with AML, this risk is largely confined to the first year

of life. Most cases of AML are not thought to have a strong genetic link. Many

doctors feel the increased risk among identical twins may be due to leukemia

cells being passed from one fetus to the other while still in the womb. Other

factors that have been studied for a possible link to AML include; Exposure to

electromagnetic fields (such as living near power lines), Workplace exposure to

diesel, gasoline, and certain other chemicals and solvents and also exposure to

herbicides or

pesticides.

6

/http://www.cancer.org/Cancer/LeukemiaAcuteMyeloidAML/DetailedGuide/

leukemia-acute-myeloid-myelogenous-risk-factors/

7

Certain signs and symptoms might suggest that a person may have

acute myeloid leukemia (AML), but tests are needed to confirm the diagnosis. Blood samples for tests for AML are generally taken from a vein

in the arm. Bone marrow samples are obtained from 2 tests that are usually

done at the same time: The samples are usually taken from the back of the

pelvic (hip) bone, but sometimes other bones are used instead. If only an

aspiration is to be done, it may be taken from the sternum (breast bone).In bone marrow   aspiration , you lie on a table (either on your side or on your

belly). The doctor will clean the skin over the hip and then numb the area and

the surface of the bone with a local anesthetic. This may cause a brief stinging

or burning sensation. A thin, hollow needle is then inserted into the bone and a

syringe is used to suck out a small amount of liquid bone marrow (about 1

teaspoon). Even with the anesthetic, most patients still have some brief pain

when the marrow is removed. A bone marrow   biopsy  is usually done just

after the aspiration. A small piece of bone and marrow (about 1/16 inch in

diameter and 1/2 inch long) is removed with a slightly larger needle that is

twisted as it is pushed down into the bone. This causes a pressure feeling,

and rarely may also cause some brief pain. Once the biopsy is done, pressure

will be applied to the site to help prevent bleeding. These bone marrow tests

are used to help diagnose leukemia. They may also be repeated later to tell if

the leukemia is responding to treatment. Spinal fluid, the cerebrospinal fluid

(CSF) is the liquid that surrounds the brain and spinal cord. Leukemia can

spread to the area around the brain and spinal cord. To check for this spread,

doctors remove a sample of CSF for testing. The procedure used to remove a

sample of this fluid is called a lumbar puncture (spinal tap). One or more of the

following lab tests may be done on the samples to diagnose AML and/or to

determine the specific subtype of AML. The complete blood count (CBC) is a

test that measures the different cells in the blood, such as the red blood cells,

the white blood cells, and the platelets. This test is often done along with a

8

differential (or diff) which looks at the numbers of the different types of white

blood cells. For the peripheral blood smear, a sample of blood is looked at

under the microscope. These tests look at how the different types of cells in

the blood appear under the microscope and how many of them there are.

Changes in the numbers and the appearance of these cells often help

diagnose leukemia.

A key element is whether the cells look mature (like normal blood cells) or immature (lacking features of normal blood cells). The most

immature cells are called myeloblasts (or "blasts" for short).The percentage of

cells in the bone marrow or blood that are blasts is particularly important. Having at least 20% blasts in the marrow or blood is generally required for a diagnosis of AML. It can also be diagnosed if the blasts have a chromosome

change that occurs only in a specific type of AML, even though the blast

percentage doesn't reach 20%. Sometimes the blasts look similar to normal

immature cells in the bone marrow. But under normal circumstances, blasts are

never more than 5% of bone marrow cells. In order for a patient to be considered

to be in remission after treatment, the blast percentage must be no higher than

5%.

For cytochemistry tests, cells are exposed to chemical stains (dyes) that

react with only some types of leukemia cells. These stains causes color changes

that can be seen under a microscope, which can help the doctor determine what

types of cells are present. For instance, one stain can help distinguish AML cells

from acute lymphocytic leukemia (ALL) cells. The stain causes the granules of

most AML cells to appear as black spots under the microscope, but it does not

cause ALL cells to change colors.

Imaging tests use x-rays, sound waves, magnetic fields, or radioactive

particles to create pictures of the inside of the body. Leukemia does not usually

form visible tumors, so imaging tests are of limited value. There are several

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imaging tests that might be done in people with AML, but they are done more

often to look for infections or other problems, rather than to look for the leukemia

itself. In some cases imaging tests may be done to help determine the extent of

the disease, if it is thought it may have spread beyond the bone marrow and

blood. These imaging test are x-ray, CT scan, MRI, ultrasound , gallium scan and

bone scan.

/ http://www.cancer.org/Cancer/LeukemiaAcuteMyeloidAML/DetailedGuide/

leukemia-acute-myeloid-myelogenous-diagnosed /

Typically AML comes on suddenly, within days or weeks. Less often, a

patient has been ill for a few months or may have a prior history

of Myelodysplastic Syndrome. AML makes people sick primarily by interfering

with normal bone marrow function. The leukemia cells replace and crowd out the

normal cells of the bone marrow, thereby causing low blood cell counts. This

insufficient number of red blood cells results in a condition called anemia, which

causes a person to be tired and pale. Lack of platelets can make you more

susceptible to bleeding and bruising, especially in the skin, nose and gums.

Lowered levels of normal white blood cells increase the risk of infection. Although

infections can be of any type, typical symptoms include: fever, runny nose,

cough, Chest pain or shortness of breath, pain with urinating, diarrhea,

occasionally, infections of the bloodstream, called sepsis, and pneumonia are the

most dangerous. General signs and symptoms of the early stages of acute myelogenous leukemia may mimic those of the flu or other common diseases. Signs and symptoms may vary based on the type of blood cell

affected. Signs and symptoms of acute myelogenous leukemia include, fever,

bone pain, lethargy and fatigue, shortness of breath, pale skin, frequent

infections, easy bruising, unusual bleeding, such as frequent nosebleeds and

bleeding from the

gums./http://www.mayoclinic.com/health/acutemyelogenousleukemia/DS00548/

DSECTION=symptoms/

10

Medical management includes chemotherapy and use of anti-neoplastic

agents. Patients with AML need to start chemotherapy right away. It is

important to get medical care in a center where doctors are experienced in

treating AML patients. There are two parts of AML treatment, called induction therapy and consolidation therapy.  The aim of induction therapy is to kill as

many AML cells as possible and get blood cell counts back to normal over time.

When the aim of induction therapy is achieved it is called a remission. A

patient in remission feels better over time and leukemia cells can't be seen in his

or her blood or marrow. Induction therapy is done in the hospital. Patients are

often in the hospital for three to four weeks. Some patients may need to be in the

hospital longer. Many different drugs are used to kill leukemic cells. Each drug

type works in a different way to kill the cells. Combining drug types can

strengthen the effects of the drugs. New drug combinations are being studied.

Two or more chemotherapies are usually used together to treat AML. Some

drugs are given by mouth. Most chemotherapies are given through

a catheter placed into a vein, usually in the patient's upper chest. The first round

of chemotherapy usually does not get rid of all the AML cells. Most patients will

need more treatment. Usually the same drugs are used for more rounds of

treatment to complete induction therapy. More treatment is usually needed even

after a patient with AML is in remission. This second part of treatment is called consolidation therapy. It is needed because some AML cells remain that are

not found by common blood or marrow tests. Consolidation therapy is also done

in the hospital. As with induction therarpy, patients may be in the hospital

for three to four weeks, or sometimes longer. Consolidation therapy may include

chemotherapy with or without an allogeneic stem cell transplant or autologous

stem cell transplant. /http://www.leukemia-lymphoma.org/all_page.adp?

item_id=8459#treatment/

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Nursing management are directed towards relieveing the signs and

symptoms of AML and managing the side effects of chemotherapy. Side effects

such as neutropenia, thrombocytopenia, anemia, mucositis, gastritis, nausea,

vomiting, diarrhea, constipation, central nervous system alterations, knowledge

deficit and ineffective coping. Preventing infection, frequently monitor the client

for pneumonia, pharyngitis, esophagitis, perianal cellulitis, urinary tract infection,

and cellulitis, which are common in leukemia and which  carry significant

morbidity and mortality. Monitor for fever, flushed appearance, chills, tachycardia;

appearance of white patches in the mouth; redness, swelling, heat or pain in the

eyes, ears, throat, skin, joints, abdomen, rectal and perineal areas; cough,

changes in sputum; skin rash. Check results of granulocyte counts.

Concentrations less than 500/mm3 put the patient at serious risk for infection.

Avoid invasive procedures and trauma to skin or mucous membrane to prevent

entry of microorganisms. Use the following rectal precautions to prevent

infections: Avoid diarrhea and constipation, which can irritate the rectal mucosa,

avoid the use of rectal thermometers, and keep perineal are clean. Care for the

patient in private room with strict handwashing practice. Encourage and assist

patient with personal hygiene, bathing, and oral care. Obtain cultures and

administer antimicrobials promptly as directed. Preventing and Managing bleeding: Watch for signs of minor bleeding, such as petechiae, ecchymosis,

conjunctival hemorrhage, epistaxis, bleeding gums, bleeding at puncture sites,

vaginal spotting, heavy menses. Be alert for signs of serious bleeding, such as

headache with change in responsiveness, blurred vision, hemoptysis,

hematemesis, melena, hypotension, tachycardia, dizziness. Test all urine, stool,

emesis for gross and occult blood. Monitor platelet counts daily. Administer blood

components as directed. Keep patient on bed rest during bleeding episodes.

Patient Education and Health Maintenance: Teach signs and symptoms of

infection and advise whom to notify. Encourage adequate nutrition to prevent

12

emaciation from chemotherapy. Teach avoidance of constipation with increased

fluid and fiber, and good perineal care. Teach bleeding precautions. Encourage

regular dental visits to detect and treat dental infections and

disease. /http://nursingcrib.com/case-study/leukemia-case-study/

Cancer is largely a preventable illness. Two-thirds of cancer deaths in

the U.S. can be linked to tobacco use, poor diet, obesity, and lack of exercise. All

of these factors can be modified. Nevertheless, an awareness of the opportunity

to prevent cancer through changes in lifestyle is still under-appreciated. The

majority of cases of AML cannot be prevented since we do not know the cause.

The few cases associated with benzene exposure are preventable with better

workplace conditions. The exact number of cases of AML that could be

prevented by avoiding exposure to automobiles is unknown, but this is

impractical for the majority of people. Diet is a fertile area for immediate

individual and societal intervention to decrease the risk of developing certain

cancers. Numerous studies have provided a wealth of often-contradictory

information about the detrimental and protective factors of different foods. There

is convincing evidence that excess body fat substantially increases the risk for

many types of cancer. While much of the cancer-related nutrition information

cautions against a high-fat diet, the real culprit may be an excess of calories.

Studies indicate that there is little, if any, relationship between body fat and fat

composition of the diet. These studies show that excessive caloric intake from

both fats and carbohydrates lead to the same result of excess body fat. The ideal

way to avoid excess body fat is to limit caloric intake and/or balance caloric

intake with ample exercise. It is still important, however, to limit fat intake, as

evidence still supports a relationship between cancer and polyunsaturated,

saturated and animal fats. Specifically, studies show that high consumption of

red meat and dairy products can increase the risk of certain cancers. One

strategy for positive dietary change is to replace red meat with chicken, fish, nuts

13

and legumes. High fruit and vegetable consumption has been associated with a

reduced risk for developing at least 10 different cancers. This may be a result of

potentially protective factors such as carotenoids, folic acid, vitamin C,

flavonoids, phytoestrogens and isothiocyanates. These are often referred to as

antioxidants. There is strong evidence that moderate to high alcohol consumption

also increases the risk of certain cancers. One reason for this relationship may

be that alcohol interferes with the availability of folic acid. Alcohol in combination

with tobacco creates an even greater risk of certain types of cancer. Exercise, higher levels of physical activity may reduce the incidence of some cancers.

According to researchers at Harvard, if the entire population increased their level

of physical activity by 30 minutes of brisk walking per day (or the equivalent

energy expenditure in other activities), we would observe a 15% reduction in the

incidence of colon

cancer. /https://www.texasoncology.com/showtypescancer.aspx?

documentid=757/

14

Chapter II

Review of Related Literature

What is Acute Myelogenous Leukemia?

“Decoding of a Acute Myeloid Leukemia Genome”

http://www.suite101.com/content/decoding-of-a-acute-myeloid-leukemia-genome-a77999#ixzz1AFvxkBHa

Acute Myeloid Leukemia (AML) is a cancer of the white blood cells and

characterized by a rapid proliferation of abnormal cells. These cancerous cells

accumulate in the bone marrow and interfere with the production of normal white

or red blood cells. When cancerous blood cells accumulate in the blood or bone

marrow, infection, anemia, or easy bleeding can frequently occur. The leukemia

cells can spread outside the blood to other parts of the body, including to organs

of the central nervous system such as brain and spinal cord.

How is AML diagnosed?

‘Hope After a Cancer Diagnosis”Anti-viral Drug Ribavirin Shows Promise in CancerTreatmenthttp://www.suite101.com/content/hope-after-a-cancer-diagnosis-a117732#ixzz1AG28qciK

Cancer drugs targeting the eukaryotic translation initiation factor gene

offers hope in cancer treatment.

Getting a cancer diagnosis can be overwhelming but there is hope in the form the

anti-viral drug, ribavirin. This according to a recent clinical trial and study

conducted on a group of cancer patients. Cancerous cells multiply without any

15

cell regulation creating tumors and growths. This is commonly caused by a

genetic mutation within a cancerous cell’s DNA. Scientists have been able to

pinpoint the source to some specific genes within the cell’s genetic code. One

commonly found gene mutation in cancer patient’s cancerous cells is within the

gene regulation of eIF4E protein. This gene is found to be impaired in about a

third of the different cancers; namely breast, colon, stomach and prostate.

How is AML treated?“Researchers discover key mutation in acute myeloid leukemiaNIH-supported discovery may lead to treatment changes”http://www.wellsphere.com/cancer-article/researchers-discover-key-mutation-in-acute-myeloid-leukemianih-supported-discovery-may-lead-to-treatment-changes-demonstrates/1275566

Researchers discover key mutation in acute myeloid leukemia

NIH-supported discovery may lead to treatment changes; demonstrates power of

The Cancer Genome Atlas strategy Researchers have discovered mutations in a

particular gene that affects the treatment prognosis for some patients with acute

myeloid leukemia (AML), an aggressive blood cancer that kills 9,000 Americans

annually. The scientists report their results in the Nov. 11, 2010, online issue

of The New England Journal of Medicine.The Washington University School of

Medicine in St. Louis team initially discovered a mutation by completely

sequencing the genome of a single AML patient. They then used targeted DNA

sequencing on nearly 300 additional AML patient samples to confirm that

mutations discovered in one gene correlated with the disease. Although genetic

changes previously were found in AML, this work shows that newly discovered

mutations in a single gene, called DNA methyltransferase 3A or DNMT3A,

appear responsible for treatment failure in a significant number of AML

patients.  The finding should prove rapidly useful in treating patients and which

16

may provide a molecular target against which to develop new drugs.

Mutations in AML“Mutations in Single Gene Predict Poor Outcomes in Adult Leukemia; Discovery May Guide Treatment for Acute Myeloid Leukemia”http://www.sciencedaily.com/releases/2010/11/101110171337.htm

ScienceDaily (Nov. 11, 2010) — Decoding the DNA of a woman who died of

acute myeloid leukemia (AML) has led researchers at Washington University

School of Medicine in St. Louis to a gene that they found to be commonly altered

in many patients who died quickly of the disease.

The findings, if confirmed in larger studies, suggest that a diagnostic test for

mutations in the gene could identify AML patients who need more aggressive

treatment right from the start. The new discovery also provides a concrete target

for developing improved therapies against AML, a fast-moving blood cancer that

kills 9,000 Americans annually.

Studying nearly 300 AML patients, the researchers found those with a mutation

in the DNA methyltransferase 3A gene, or DNMT3A, survived for a median of just

over one year after their diagnosis, compared with nearly 3.5 years for those

without a mutation. The research is published online Nov. 10 in the New England

Journal of Medicine.

Chemotherapy for AML“Intensive Chemotherapy May Be Harmful to Most Older Patients With Acute Myeloid Leukemia”http://www.sciencedaily.com/releases/2010/07/100729091458.htmScienceDaily (July 29, 2010) — The prognosis for nearly three-quarters of elderly

patients on intensive chemotherapy for acute myeloid leukemia (AML) is poor,

with a median survival of less than six months, according to a study published

online in Blood, the journal of the American Society of Hematology.

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Recent studies have suggested that intensive chemotherapy might benefit elderly

patients with AML, but we found that not to be the case," said Hagop Kantarjian,

MD, Chairman of the Leukemia Department at The University of Texas M. D.

Anderson Cancer Center in Houston and senior author of the study. "Patients

who did not have any of the eight-week mortality predictors we identified in the

study may benefit from the more intense treatment, but for the majority of AML

patients of advanced age, lower-intensity treatments are a better, less risky

option."Symptoms of AML include fever, frequent infections, tiredness, pale skin,

shortness of breath, easy bleeding or bruising, and pain in the bones or joints.

Because the disease develops rapidly, doctors usually begin treatment

immediately after diagnosis. Treatments for AML include chemotherapy or a

transplant with blood cells obtained from the circulating blood or cord blood,

though, for most elderly patients, the risks of serious side effects eliminate

transplant as a viable option.

18

Chapter IIIClient Presentation

PATIENT PROFILE

Name: (alyas) “Kiko”Age: 24 years oldBirthday: August 03, 1986Address: Imus, CaviteNationality: FilipinoCivil Status: SingleReligion: Roman CatholicAdmission: November 11, 2010 @ 11:00 a.mChief Complaint: Easy fatigability and sudden weight lossAdmitting Physician: Dr. R. EspinozaHospital: St. Luke’s Medical CenterWard: Private RoomAdmitting Diagnosis: Stage 4 Acute Myelogenous LeukemiaWeight upon admission: 125lbs/56.82kgHeight: 5’8Blood type: type ABlood Pressure upon admission: 80/50mmhg

Past Medical History

The patient was diagnosed of anemia when he was 13 years old and was prescribed to take iron supplements. He took the iron supplements for 3 years. Upon entering college he discontinued taking his medications. He finished B.S. accountancy and worked as a bank accountant in Banco de Oro branch in Manila for 3 years. During these years, he often experience flu, cough and colds. He also often experience easy fatigability upon doing ADLs.

Present

The present illness has begun 6 months ago with sign and symptoms of easy fatigability, presence of bruise in some areas of the body and sudden weigh loss of 2 kilograms in 2 weeks which prompt the patient to seek medical consultation. He had undergone certain laboratory examination such as blood cell tests and bone marrow test. He was then advised to undergo chemotherapy because he was diagnosed of Stage 4 of Acute Myelogenous Leukemia.

19

The 13 Areas of AssessmentI. Psychosocial Status

The patient is a Caviteño and was raised by his parents in their province. He worked as a bank accountant in Banco De Oro branch in Manila. They live in a concrete house. He is Roman Catholic. The patient is the youngest among the brood of three. His father died two years ago because of leukemia. The patient is 24 years old and single. His family supports him in his treatment. According to his mother, he loves to spend his time with his family.

II. Mental and Emotional Status

The patient is conscious, he can still respond to verbal stimuli, and has some decreased deep tendon reflexes. He is oriented to time, place and can recognize people around him.

The patient is a degree holder so he can easily follow instructions. He has a good memory and can recall things in the past.

The patient is depressed about her condition and he has lost hope in recovering from his illness. He is afraid that any time he may die. Sometimes he cry at night and at times he gets mad at his family because he feels like they don’t do their best to alleviate his condition.

NURSING DIAGNOSIS:

ANXIETY r/t current condition of illness as manifested by verbalization of feelings of hopelessness and fear of the unknown

ANTICIPATORY GRIEVEING r/t loss of hope to survive his illness as manifested by periods of crying and expression of sadness.

III. Emotional Status

The patient is 24 years old, he is mobile and was placed in a private room. The patient is immunosuppressed so the health personnel and significant others are observing for strict isolation precaution. The patient’s watcher is his mother. He is not manifesting

20

any infectious disease and has no presence of infected wound in his skin. His mother and significant others as well the health personnel, are observing proper hand washing before, during and after contact with the patient. The patient is wearing a mask every time he goes out of his room assisted by his mother. He practices meticulous personal hygiene. The patient’s room is well ventilated, it is air conditioned and spacious. Because the patient is sensitive to light, they use dim light in the room to protect eye strains that will aggravate more pain to his condition.

NURSING DIAGNOSIS:

RISK FOR INFECTION r/t immunosuppression / compromised immune system

IV. Sensory Status

Because the patient is sensitive to light, they use dim light in the room to protect eye strains that will aggravate more pain to his condition. The patient has no difficulty identifying odors. The patient is able to distinguish sweet, sour, salty and bitter taste. Because of chemotherapy, he manifests unusual sensation like nausea and vomiting. The patient is able to discriminate sharp, dull, light, and firm touch. He can perceive roughness from smoothness.

The patient, with his condition, speaks slowly because he tires easily. The patient speaks using “Tagalog”. He is able to understand commands, and imitate speeches normally.

The patient is oriented about the time, place, person, understands verbal and written words. The patient has complaints of irritability because of the hospital setting and also agitated due to the effects of his treatment and with his condition.

NURSING DIAGNOSIS:

FATIGUE r/t decreased oxygen level in the blood as manifested by tiring easily and agitation when doing ADLs secondary to anemia

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ALTERED SENSORY PERCEPTION r/t increased sensitivity to light as manifested by itching and teary eyes when exposed to light secondary to chemotherapy

V. Motor Status

The physician ordered for frequent rest periods and ordered to monitor I and O as well as signs of bleeding. The patient complains that some of his deep tendon reflexes decreased. Upon assessing deep tendon reflex, results reveals: grading in the upper and lower extremities are biceps reflex: +1, triceps reflex: +1 and knee jerk reflex: +1 which means the reflexes are hypoactive and other reflexes in both extremities has a grade of +2 which is normal. He also complains of joint pain with pain scale of 8/10. The patient was prescribed to take pain medication (Morphine Sulfate). The patient needs assistance when doing ADLs because he is weak.

NURSING DIAGNOSIS:

ACTIVITY INTOLERANCE r/t decrease in number of red blood cells as manifested by weakness and easy fatigability

ACUTE PAIN r/t cancer cells in the bones and compromised immune system as manifested by joint pain

VI. Nutritional Status

Before the patient was confined, he loves eating foods rich in preservative. The patient was ordered for small frequent feedings, small portion of calorie, increase protein, bland and low residue diet. He verbalizes the desire to comply with the diet and the importance of complying with it.

She also feels nauseated and vomited a few times every after chemotherapy. The patient only eats because his mother forces him to do so. Because of the effects of chemotherapy agents and compromised immune system, the patient has stomatitis. The patient has complete set of teeth with no gum problems. The patient cannot easily swallow the foods being introduced to him because of his stomatitis. He eats very little amount of food due to his stomatitis. He had also loose weight from 56.82kg to 47kg.

NURSING DIAGNOSIS:

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IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS r/t effects of chemotherapy as manifested by nausea, vomiting and inability to chew foods easily because of sores in the mouth

PAIN r/t inflammation of the oral mucosa as manifested by gums that bleed easily and inability to chew foods properly

VII. Elimination Status

The patient is having diarrhea due to the effects of chemotherapy. The patient has a specific gravity of 1.012 and slightly turbid colored urine with some precipitate. There are no artificial orifices used like ileostomy or colostomy. The patient is also undergoing blood transfusion of packed red blood cell and platelet.

NURSING DIAGNOSIS:

DIARRHEA r/t effects of chemotherapy as evidenced by 3 or more passage of loose stools every after treatment

RISK FOR FLUID VOLUME DEFICIT r/t 3 or more passage of loose stools secondary to chemotherapy

VIII. FLUID AND ELECTROLYTE STATUS

The patient has 2000cc fluid intake and 1,200cc 24-hour urine output. Serum electrolytes reveals: the following results: K= 3.9mmol/L, Na=136.2mmol/L, Ca= 8.4mmol/L. The patient has PNSS infusion regulated at KVO. Uric acid level is 8.1mg/dL which also causes joint paint to the patient.

NURSING DIAGNOSIS:

ACUTE PAIN r/t elevated uric acid in the blood as manifested joint pain

IX. Circulatory Status

The patient has weak and irregular pulse with a pulse rate of 85bpm. The patient has a blood pressure of 80/50mmHg. Upon assessment, the patient’s capillary refill is about 3-4seconds.

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Laboratory results reveals: blood cell count and examination: hct=36%, hgb= 12%, rbc count=3.8mil/mm3, wbc count= 9,500/mm3, platelet count=180,000/mm3. Bone marrow test: 26% of myoblasts or leukemic cells found in the blood.

The patient’s skin is pale, slightly cold to touch, with presence of bruises on some areas of the body, in the upper and lower extremities. The patient experiences fatigue.

NURSING DIAGNOSIS:

INEFFECTIVE TISSUE PERFUSION r/t inadequate red blood cell production and low hemoglobin concentration as manifested by fatigue, pale skin and shortness of breath

RISK FOR BLEEDING

IMPAIRED SKIN INTEGRITY r/t low platelet count as manifested by bruises on the skin

X. Respiratory Status

The patient has shallow, irregular breathing with 26cpm. The patient experiences shortness of breath.

NURSING DIAGNOSIS:

IMPAIRED GAS EXCHANGE r/t decrease oxygen level in the blood as manifested by shortness of breath upon doing ADLs secondary to anemia

XI. Temperature Status

The patient is feverish with a temperature of 37.9C. The room is well ventilated with a room temperature of 22C.

XII. INTEGUMENTARY STATUS

There are presence of bruises on some areas of the body which makes the patient hesitant and conscious to look at himself. Because of loss of hair, he feels that he looks so unattractive. He had also loosed a total weight of 9kg. He doesn’t want look at himself at the mirror. The patient is being taken cared by his

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mother. His mother assists him in taking a bath. Oral hygiene is emphasized to the patient.

NURSING DIAGNOSIS:

BODY IMAGE DISTURBANCE r/t effects of chemotherapy as manifested by bruises on the skin and loss of hair

LOW SELF-ESTEEM r/t physical changes in the body as manifested by bruises, loss of hair, weight loss and verbalization of unattractiveness

XIII. COMFORT AND REST STATUS

The patient has disturbed sleeping pattern because of chemotherapy. He sometimes can’t sleep at night because of being bothered by his condition. He’s also scared that he will no longer be awake. He still can’t accept his current situation. He undergoes chemotherapy and has two days of rest periods in one week.

NURSING DIAGNOSIS:

SLEEP DISTURBANCE r/t anxiety as evidenced by verbalization of feelings of fear and in denial of his illness.

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Chapter IV

Nursing Analysis

Nursing Problems

INEFFECTIVE TISSUE PERFUSION r/t inadequate red blood cell production as manifested by fatigue, pale skin and shortness of breath

The patient has anemia which is one of the symptom of AML. Related to anemia is the nursing diagnosis above. There is ineffective tissue perfusion because there is an inadequate red blood cell production, thus there is a decrease hemoglobin concentration in the blood. Hemoglobin transports oxygen to the body. This is a priority because it falls under one of the ABCs which is circulation. If there is an inadequate oxygen supply in the body, then our circulation will be compromised. Oxygen is one of the basic need of a human being according Maslow’s hierarchy of needs.

RISK FOR INFECTION r/t immunosuppression / compromised immune system

The patient is at risk for infection because he has a high WBC count and infection is one of the symptoms of AML. The patient’s immune system is compromised also due to the effects of chemotherapy that’s why he is at risk for infection. Signs of infection are gum bleeding, fever, cough and colds and others. This is second priority because we need to avoid infection so that the patient’s condition will not get worst. And according to Betty Neuman’s Systems model, a human is an open system where it consists of a basic structure and a central core surrounded by two concentric rings referred to as lines of resistance. The

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lines of resistance, in his model represents internal factors that defend the client against a stressor and infection is a stressor. Thus, she means that as nurses we need to do interventions to prevent stressors that will enter a person’s system

IMPAIRED SKIN INTEGRITY r/t low platelet count as manifested by bruises on the skin

The patient has bruises on the skin due to low platelet count. Low platelet is a condition called thrombocytopenia. The patient is bruises easily.

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