Case study presentation on Acute Lymphocytic leukemia

1. Case presentation
on
‘Acute Lymphocytic leukemia’
Prepared by :
Kalpana kawan
Roll no. 06
BNS 3rd year

2. General Objective
• At the end of this presentation, participants
will be able to know about case study of Acute
Leukemia

3. Specific Objectives
At the end of this presentation, participants will
able to know:
• History of the patient
• physical examination finding
• Developmental task of adolecence
• Diseases profiles : Acute Leukemia

4. Specific Objectives contd…..
• Drugs Profile
• Nursing Theory application
• Nursing care plan
• Patient progress note
• Health education
• Plan discharge teaching
• What I learned from case study
• References

5. History
Biodemographic data
• Name :Sandesh Sunuwar
• Age :15 years
• Sex : Male
• Education status : Literate (Class 9)
• Occupation : Student
• Religion : Hindu
• Name of Guardian : Jhapatmaya Sunuwar
• Relationship : Mother
• Address :Khijidenba-3, Okhaldhunga, provience no.1

6. History Contd……
• Bed no : 16
• Ward : Oncology Ward
• I.P No. : 659940
• Date of admission : 2078/07/15
• Provisional Diagnosis : Acute Leukemia
• Final diagnosis : Acute Leukemia
• Unit : Hematology
• Attending Doctor : Dr. Anjan Shrestha

7. History contd……..
Chief complaints
• Fever for 1 week
• Shortness of breath for 2 months
• Dizziness for 2 months
• Right hypochondrium region pain

8. History contd……..
Present health history
Past health history
Prenatal and birth history
Family history
• There is history of asthma to his grandfather
since 7 year.

9. History Contd..
• Family tree

10. History Contd..
Nutritional and dietary history
Personal history
 Socio-economic and environment history
Psycological history
Health seeking behaviour

11. Physical examination
Findings of Physical examination:
• Patient's general state of health seem tired, fatigue,
• Patient's vital signs are BP-100/60mmhg, pulse-
120/min,temperature-99.80F,respiration-20/min,
Spo2- 96% in room air
• Patient malnourish. Weight 50kg, height-168cm,
BMI- 17.71 kg/m2
• Head: Danddruff present, Old scar of cut injury
present on head

12. Physical examination contd…
• Skin : pale
• His personal hygiene seem unsatisfactory. Poor hair
hygiene
• Eye: left corneal opacity
• Ear: Wax present on inspection.
• Lips: Lip was dry and crack
• Abdomen:
• - 3cm long old scar present over left lumber region.

13. Developmental task of Adolecence
SN According to book In my patient
1. Accepting one’s physique He accepts his own physique. He is comfort
with how he look.
2. Accepting a masculine role He accepts his masculine role but is not
practicing these days due to health condition.
3. Development of own identity He develops his own identity being a resposible
member of his family and a good students in
his school.
4. Establishing new relation
with new mates of both sexes
He is able to make new friendship with people
of both sexes of his age.
7. Acceptance of and
adjustment to certain groups.
He accepts his transformation as an patient and
is co-operative during hospitalization and
different procedures
8. Achieving emotional
independence from parents
and other adults.
He is emotionally independence from his
parents and other adults.

14. Anatomical and physiological
review of
Bone marrow and Blood

15. Anatomy contd….
• Bone marrow is a spongy substance found in
the center of the bones such as hip and thigh
bones.

16. Anatomy contd….
• Types of bone marrow: 2 types
• The are :
1. Red bone marrow, known as myeloid tissue,
2. Yellow bone marrow, known as fatty tissue.

17. Anatomy contd….
Bone marrow stem cells
• 2 types of stem cells: hematopoietic and
mesenchymal
• Red bone marrow consists of a delicate, highly
vascular fibrous tissue containing hematopoietic
stem cells. These are blood-forming stem cells.
• Yellow bone marrow contains mesenchymal stem
cells, or marrow stromal cells. These produce fat,
cartilage, and bone.

18. Anatomy contd….
• Blood cell formation

19. Anatomy contd….
• Hematopoiesis
The process of developing different blood cells
from these stem cells is known
as hematopoiesis

20. Disease profile

21. Leukemia
• Definition
Leukemia is a clonal
malignant neoplasm of the
hematopoietic stem cells
charecterized by the
proliferation of
normal blood cells.

22. Defination contd…
• Leukemia is cancer of the body's blood-
forming tissues, including the bone marrow
and the lymphatic system.
(Basavanthapa, BT. 2015)

23. Classification
Base on speed of disease development:
• Acute leukemia
• Chronic Leukemia
Base on cell type
• Lymphocytic leukemia
• Myelogenous or myeloid leukemia

24. Classification contd…..
There are four major types of leukemia
• Acute lymphocytic leukemia (ALL)
• Acute myeloid leukemia (AML)
• Chronic lymphocytic leukemia (CLL)
• Chronic myeloid leukemia (CML)

25. Acute lymphocytic leukemia (ALL)
• Acute lymphocytic leukemia is also known as
acute lymphoblastic leukemia or ALL.
• It result from an uncontrolled proliferation of
immature cells (lymphoblasts ) derived from
the lymphoid stem cell.
• This is the most common type of leukemia in
children and accounts for 15% in adults.

26. Epidemiology
• Acute lymphocytic leukemia is more common
in males than in females
• Usually occur before 14 years of age.
• Peak incidence is between 2-9 years of age and
in older adult.

27. Epidemiology contd..
• The rate of new cases of acute lymphocytic
leukemia was 1.8 per 100,000 men and women
per year.
• The death rate was 0.4 per 100,000 men and
women per year.
• Prevalenc: In 2018, there were an estimated
103,536 people living with acute lymphocytic
leukemia in the United States.
(Centers for diseases Control and
Prevention, 2018)

28. Classification of ALL
• ALL is classified morphologically
using French-American-British(FAB), There
is 3 subtype.
1. ALL- L1
2. ALL- L2
3. ALL-L3 (Burkitt’s leukemia)

29. Classification of ALL contd….
1. ALL –L1
Size- small
Cytoplasm scanty basophilic
N/C ratio- high
Nuclear membrane- regular
Nucleoli- invisible or indistinct

30. Classification of ALL contd….
2. ALL-L2
Size of blast – Large and heterogenous
Cytoplasm – moderate
N/C ratio lower
Nuclear membrane irregular
with clefting
Nucleoli- prominent, 1-2

31. Classification of ALL contd….
3. ALL- L3 (Burkitt’s leukemia)
Size of blast- large and homogenous
Cytoplasm- moderate and intensely basophilic
N/C ratio – lower
Nuclear membrane-regular
Nucleoli- prominent, 1-2

32. Etiology and Risk factor according
to book picture and patient
SN According to Book In my patient
1. Exact cause is unknown Present
2. Genetic factors Absent
3. Over exposure to ionizing radiations
and chemicals
Absent
4. Congenital abnormalities: Down’s
syndrome
Absent
5. Infection Absent

33. Pathophysiology
• Accumulation. Due to the precipitating factors,
immature, non-functioning WBCs appear to
accumulate first in the tissue where they originate
(lymphocytes in lymph tissue, granulocytes in
bone marrow).
• Infiltration. These immature WBCs then spill
into the bloodstream and from there infiltrate
other tissues.
• Malfunction. Eventually, this infiltration results
in organ malfunction because of encroachment
and hemorrhage.

34. Pathophysiology

35. Sign and symptoms according to
book and patient
SN According to Book In my patient
1 Fever Present
2 Pale skin Present
3 Anemia Present
4 Dizziness Present
5 Bleeding Absent
6 Anorexia Present
7 Fatigue Present
8 Weakness and feeling tired Present
9 Breathlessness Present
10 Bone, joint and abdominal pain Absent

36. Sign and symptoms contd….
S
N
According to book In my patient
11 Generalized lymphadenopathy, infection, weight
loss
Absent
12 Hepatomegaly Absent
13 Spleenomegaly Absent
14 Headache Absent
15 Mouthsores Absent
16 Pitting edema in the lower limbs and/or abdomen Absent
17 Increased ICP(nausea, vomiting, lethargy, cranial
nerve dysfunction)
Absent
18 Petechiae, which are tiny red spot or lines in the
skin due to low plates levels.
Absent
19 Testicular enlargement Absent

37. Diagnostic test of Acute Lymphocytic
Leukemia
SN According to book In my patient
1 History Done
2 Physical examination Done
3 Blood test:
-Low RBC count, Hb, Hct
- Low platelet count
-Low , normal or high WBC
count
Done
-RBC:2.31
million/cum
-Platelets:79000/cu
-TLC:3300/cum
4 Peripheral blood smear Done

38. Diagnostic test
SN According to book In my
patient
5 Bone marrow aspiration and biopsy Done
6 Imaging test: X-ray,CT scan,
Ultrasound scan may help determine
whether cancer has spread to the brain
and spinal cord or other parts of the
body.
Done(USG
of abdomen/
pelvis –
minimal
pelvic acites
7 Lumber puncture: The spinal fluid is
tested to see whether cancer cells have
spread to the spinal fluid.
Done
(report due)

39. Treatment
Medical Management
Chemotherapy
• Chemotherapy is the initial treatment of
choice, and most people with ALL receive a
combination of medications.

40. Treatment cont…
Chemotherapy for ALL consists of three phases:
1. Remission induction: Its aim to rapidly kill most
tumor cells.
 Chemotherapy agent:
 steroids - prednisolone or dexamethasone
 vincristine
 asparaginase
 daunorubicin

41. Treatment cont…
2. Intensification/Consolidation
• Given immediately after induction therapy
for several months.
• Includes the same drugs as those used in
induction but at higher dosages to further
reduce tumor burden.

42. Treatment cont…
3. Maintenance therapy.
• Treatment with lower doses of the same drugs
used in induction or other drugs given every 3
to 4 weeks for a prolonged period of time.
• Chemotherapy agent:
oral mercaptopurine
oral methotrexate
vincristine and oral corticosteroids

43. Treatment cont…
Biological therapy
• It is used to help the immune system to
recognize and attack leukemia cells. Eg.
Rituximab

44. Treatment cont…
Targetted Therapy
• In targeted therapy, uses drugs that attacks the
specific vulnerabilities within cancer cells. Eg.
Imatinib.

45. Treatment cont…
Radiation therapy
• Radiation therapy uses X-rays or other high
energy beams to damage the leukemia cells
and to stop their growth.

46. Treatment cont…
Supportive management
• Cytopenias
Transfusion support: Platelets and packed red cell
transfusion when necessary.
• Prevention of Tumor Lysis Syndrome
Intravenous hydration
Allopurinol
Correction of electrolyte
disturbances(Hypocalcemia, hyperphosphatemia)

47. Treatment cont…
• Antibiotic prophylaxis
Prophylaxis with antibiotics or antifungals
during neutropenia.
Acyclovir prophylaxis

48. Treatment cont…
Surgical management
• Stem cell transplantation
It is procedure to replace diseased bone
marrow with healthy bone marrow.

49. Management done in my patient
• Chemotherapy
1st Dose (2078/08/09)
 Inj.Dexona 10 mg IV
 Inj.Vincristine 1.5mg/m2 IV state
Inj Daunorubicin 25 mg/m2 IV in
100ml NS IV over 30min
2nd dose (2078/08/12)
Inj L- Asparaginase 5000IU IM

50. Management done in my patient
• Supportive management
Fresh Frozon Plasma
Packed red cell trasfusion
Iv fluid (Inj Normal saline)
Antibiotic and antifungal
Isolation

51. Nursing management
• Assess the general condition of the patient.
• Closely monitor the lab value.
• Maintain good IPR with the patient.
• Provide psychological support.
• Instruct the patient to have a well balanced
diet.
• Monitor vital signs

52. Nursing management
• Include family members in providng care.
• Explain the side effects of chemotherapy
• Administer antibiotics.
• Maintain aseptic techniques while doing the
procedures
• Proper isolation of the patient.
• Provide health education to the patient.

53. Complications
• Decreased resistance to infection
• Anemia
• Thrombocytopenia
• Bleeding tendency
• Infection
• Tumorlysis syndrome
• Mucositis
• Renal dysfunction
• Nutritional depletion
• Depression and anxiety

54. Prognosis
Parameters Good Poor
WBC Low High
Gender Girls Boys
Age Child Adult or infant
Response to
treatment
Rapid
<1 week to clear
blasts from blood
Slow
>1 week to clear
blasts from blood
Time to remission <4 weeks >4 weeks
Mediastinal mass Absent Present

55. Drugs used in my patient
• Tab. Levofloxacin 750 gm PO
• Tab Bactrim DS P/O OD alternate day
• Tab Pantoprazole 40 mg PO OD
• Tab Flovin 5mg P/O OD
• Tab Fluconazole 150mg P/O BD
• Tab PCM 1 gram P/O SOS
• Tab warfarin 2 mg P/O OD

56. Application of nursing theory
• There are numbers of nursing theories and one
of those theories is the self care deficit theory
by Orem, which I have applied for my case
study patient during my nursing care.

57. Nursing Process
Assessment
• Obtain health history, focusing on fatigue, weight
loss, night sweats, and activity intolerance.
• Assess for sign of bleeding and infection.
• Evaluate splenomegaly, lymphadenopathy and
hepatomegaly.
• Assess the nutritional status.
• Assess vital signs.
• Assess respiratory status

58. Nursing Diagnosis
• Actual Nursing diagnosis
1. Fatigue related to low hemoglobin levels.
2. Increased body temperature related to
potential for infection.
3. Imbalance nutrition less than body
requirements related to fatigue and anorexia.
4. Anxiety related to knowledge deficit about
disease process

59. Nursing Diagnosis contd….
• Risk nursing diagnosis
5. Risk for infection related to neutropenia
secondary to leukemia.
6. Risk for deficient fluid volume and electrolyte
imbalance related to potential for fever,
sweating and use of antibiotics.
7. Risk for impaired skin integrity related to
toxic effects of chemotherapy.

60. Nursing Intervention
• Decreasing fatigue
• Reducing fever
• Nutrition
• Maintaining fluid and electrolyte balance
• Preventing and managing infection and
bleeding
• Managing anxiety

61. Patient progress report

62. Health Education During
Hospitalization
• Nutrition
• Physical care and maintenance of hygiene
• Rest and sleep
• Reporting
• Prevention of infection
• Family Support
• Protect skin integrity
• Side effect of chemotherapy

63. Discharge planning
• Nutrition
• Medication
• Hygiene maintainence, infection prevention
• Isolation
• Rest and exercise
• Complication
• PICC line care
• Injury/bleeding precaution
• Follow up care

64. What I learned from case study
• About the disease
• About the patient and his family
• About the nursing care
• Nursing theory application

65. References
• Basavanthapa, BT. (2015) Medical surgical
nursing(3rd ed). Jaypee Brothers Medical
Publisher(P)Ltd. Pageno.1024-1025
• Ashalatha, PR. (2015) Textbook of anatomy and
physiology for nurses(4th ed). Jaypee Brothers
Medical Publisher(P)Ltd. Pageno.79-98
• Black, J.M. Hawks, J.H. (2009) Medical surgical
nursing(8th ed). Elsevier. Page no.2115-2120
• Ameltzer, S.C. Bare, B. (2004) Brunner and
suddarth’s medical surgical nursing(10th ed). J.B.
Lippincott company Pageno. 900-905

66. References contd…
• Hinkle, J. L. Cheever, K. H. (2015) Brunner and
suddarth’s medical surgical nursing(13th ed). J.B.
Lippincott company.page no.942-951
• Retrive from Acute Lymphocytic Leukemia
Nursing Care Management: Study Guide
(nurseslabs.com) on Nov 27, 2021
• Gulanik M,(2003).Mosby’s Nursing Care Plan.(5th
edition).Mosby.page no.1019-1034.
• Adhikari. Raj Devi(2010), Nursing Theories and
Models, 2nd edition, Makalu house publication,
ISBN:978-9937-503-25-9