1 Chapter I THE PROBLEM AND ITS SCOPE This chapter presents the rationale of the study, scope and limitations,significance of the study, nursing theoretical background, review of relatedliterature and flow of the study. RATIONALE OF THE STUDY The researcher is a level IV nursing student, have been assigned in theMedical Ward for the school year 2009 – 2010 chose these study among themany cases in the area primarily because the researcher is the primary caregiverof the patient and find the case a new and interesting topic to learn. It is also agreat learning opportunity for the researcher who has just encounteredLeukemia specifically the Acute Myelocytic Leukemia. With that, the researcher aim to gain all possible knowledge about AcuteMyelocytic Leukemia. Most importantly, aside from learning the medicalinterventions with the client’s case and all possible surgeries that facilitatetreatment, the researcher also aim to know the nursing care management ofpatients affected with this condition. Endowed with such knowledge, theresearcher aim to provide a holistic and the best quality nursing care to patientswith the aforementioned disease. Furthermore, the case is Acute MyelocyticLeukemia therefore; there is still chance of recovery depending on how it isbeing treated and how the pt. responds to initial treatments. This study is adescriptive in-depth analysis of a client who is afflicted with Acute MyelocyticLeukemia. This aims to give a clear, scientific and analytic view of the conditionand how it came to be through analyzing thoroughly and comprehensively all thegathered relevant data and relate them both to client and his existing conditions.
2 SCOPE AND LIMITATIONS The study was conducted at Perpetual Succour Hospital, 2B, Room 236.The patient was diagnosed with Acute Myelocytic Leukemia. There was only onerespondent. Also included was his significant others but only limited. Theresearcher has only three days monitoring and rendering service to the patient.
3 SIGNIFICANCE OF THE STUDY The effect of this Critical Analysis Report is envisioned to be beneficial to thefollowing entities: community, readers and to the one who make this study.To the community: This study will enable them to know the importantinformation about leukemia especially Acute Myelocytic Leukemia or expresstheir problems and difficulties encountered in dealing with this kind of illness.To the Readers: The study will provide them information regarding with AcuteMyelocytic Leukemia. This will help them to be aware that this kind of illness islife-threathening.To the one who make this study: This study has given to develop self-confidencein approaching and dealing with patient diagnosed with Acute MyelocyticLeukemia. And also to analyze the primary responsibilities and roles of the nurseas part of the entire health care team and contain an effective and efficienthealth care management concerning the care of a sick child.
4 NURSING THEORETICAL BACKGROUNDThis study is based on the theory of Faye Glenn Abdellah- 21 Nursing Problems.Faye Glenn Abdellah – Twenty-One Nursing Problems Although Abdellah spoke of the patient-centered approaches, she wrote ofnurses identifying and solving specific problems. This identification andclassification of problems was called the typology of 21 nursing problems. Adbellah and her colleagues thought the typology would provide a methodto evaluate a student’s experiences and also a method to evaluate a nurse’scompetency based on outcome measures.” (Tomey & Alligood, Nursing theoristsand their work 4th ed., p. 115. Typology of 21 nursing problems 1. To facilitate the maintenance of a supply of oxygen to all body cells 2. To facilitate the maintenance of nutrition of all body cells 3. To facilitate the maintenance of fluid and electrolyte balance 4. To facilitate the maintenance of elimination 5. To maintain good body mechanics and prevent and correct deformities 6. To promote optimal activity: exercise , rest and sleep 7. To facilitate the maintenance of regulatory mechanisms and functions 8. To maintain good hygiene and physical comfort 9. To promote safety through the prevention of accidents, injury, or other trauma and through the prevention of the spread of infection 10. To facilitate the maintenance of sensory function
5 11.To facilitate the maintenance of effective verbal and non verbalcommunication 12. To promote the development of productive interpersonal relationships 13. To facilitate progress toward achievement of personal spiritual goals 14. To accept the optimum possible goals in the light of limitations, physical and emotional 15. To recognize the physiological responses of the body to disease conditions 16. To identify and accept positive and negative expressions, feelings, and reactions 17. To identify and accept the interrelatedness of emotions and organic illness 18. To create and / or maintain a therapeutic environment 19. To facilitate awareness of self as an individual with varying physical, emotional, and developmental needs 20. To use community resources as an aid in resolving problems arising from illness 21. To understand the role of social problems as influencing factors in thecase of illness
6 REVIEW OF RELATED LITERATURE Leukemia is a malignant disease of the blood-forming organs. TheAmerican Cancer Society estimated that in 2003 about 30,600 new cases ofleukemia would be diagnosed , and about 21,900 deaths would be attributed tothe disease. Leukemia is the most common malignancy in children and youngadults. Half of all leukemias are classified as acute, with rapid onset andprogression of disease resulting in 100% mortality within days to months withoutappropriate therapy. The remaining leukemias, classified as chronic, have a moreindolent course. In children 80% are lymphocytic and 20% are nonlymphocytic.In adults the percentages are reversed, with 80% no lymphocytic (Black andHawks, 2005). Acute myelocytic (myeloid, myelogenous, myeloblastic, myelomonocytic)leukemia is a life-threatening disease in which the cells that normally developinto neutrophils, basophils, eosinophils, and monocytes become cancerous andrapidly replace normal cells in the bone marrow (Freireich, 2008). Acute leukemia is believed to begin in a single somatic hematopoieticprogenitor that transforms to a cell incapable of normal differentiation. Acutemyeloid leukemia is a very heterogeneous disease from a molecular standpoint;oncogenic transformation into a leukemic stem cell may occur at different stagesof normal hematopoietic cellular maturation, from the most primitivehematopoietic stem cell to later stages, including myeloid/monocytoid progenitorcells and promyelocytes. This determines which subtype of acute myeloidleukemia results, often with very different behavior and growth characteristics(Weinblatt, 2009). Acute myeloid leukemia (AML) is one of the most common types ofleukemia among adults. This type of cancer is rare under age 40. It generallyoccurs around age 65. AML is more common in men than women. Persons with
7this type of cancer have abnormal cells inside their bone marrow. The cells growvery fast, and replace healthy blood cells. The bone marrow, which helps thebody fight infections, eventually stops working correctly. Persons with AMLbecome more prone to infections and have an increased risk for bleeding as thenumbers of healthy blood cells decrease (American Cancer Society, 2007).Most of the time, a doctor cannot tell you what caused AML. However, thefollowing things are thought to lead to some types of leukemia, including AML: • Certain chemicals (for example, benzene) • Certain chemotherapy drugs, including etoposide and drugs known as alkylating agents • RadiationProblems with your genes may also play a role in the development of AML.You have an increased risk for AML if you have or had any of the following: • A weakened immune system (immunosuppression) due to an organ transplant • Blood disorders, including: o Polycythemia vera o Essential thrombocythemia o Myelodysplasia (refractory anemia) • Exposure to radiation and chemicalsMortality/Morbidity • In 2007, an estimated 8990 deaths from acute myelogenous leukemia (AML) occurred in the United States. Of these, 5020 occurred in men and 3970 occurred in women. • In adults, treatment results are generally analyzed separately for younger (18-60 y) and older (>60 y) patients with acute myelogenous leukemia (AML).
8 o With current standard chemotherapy regimens, approximately 30-35% of adults younger than 60 years survive longer than 5 years and are considered cured. o Results in older patients are more disappointing, with fewer than 10% of surviving over the long term. (Seiter, 2009). Childhood acute myeloid leukemia (AML) is a cancer of the blood-formingtissue, primarily the bone marrow . AML is also called acute nonlymphocyticleukemia or acute myelogenous leukemia. There are several subtypes of AML. Itis less common than acute lymphocytic leukemia (also called acute lymphoblasticleukemia or ALL), another leukemia that occurs in children and adolescents.Children with Down Syndrome have an increased risk of developing acutemyeloid leukemia during the first three years of life (National Institutes of Health,National Cancer Institute, Childrens Oncology Group, 2005).
9 Flow of the Study Input Throughput/Process OutputA case of 2 year old, Management Recommendations:male patient • Medical The patient/S.O isdiagnosed with Management advised to alwaysAcute Myelocytic • Pharmacological maintain a cleanLeukemia. Treatment environment, limit visitors, and do ROMHe complained of exercises and assistancepersistent on and off in performance offever, and cough patient’s activities ofthus prompted his daily living.admission. Prognosis: Good- if treatedHe has no known immediately withheredo-familial chemotherapy anddisease. medical mgt. Poor- if untreated immediately, it would lead to sepsis then eventually death. Figure 1 Schematic Diagram DEFINITION OF MEDICAL/ NURSING TERMS
10• Anatomy – is a branch of biology and medicine that is the consideration of the structure of living things• Physiology – is the study of the mechanical, physical and biochemical functions of living organisms• Pathophysiology – is the study of the changes of normal mechanical, physical and biochemical functions, either caused by a disease, or resulting from an abnormal syndrome• Gordon’s Functional Health Pattern – is a method devised by Marjory Gordon to be used by nurses in the nursing process to provide a more comprehensive nursing assessment of the patient• Physical Assessment – the part of the health assessment representing a synthesis of the information obtained in a physical examination. It involves the detailed examination of the body from head to toe using the techniques of observation/inspection, palpation, percussion and auscultation.• Accumulation- increase or growth by addition especially when continuous or repeated <accumulation of interest>.• Acetaminophen- A drug that reduces pain and fever (but not inflammation). It belongs to the family of drugs called analgesics.
11 • • Acute leukemia- A rapidly progressing cancer that starts in blood-formi tissue such as the bone marrow, and causes large numbers of white blood ce to be produced and enter the blood stream. Acute myeloid leukemia- An aggressive (fast-growing) disease in which too many myeloblasts (immature white blood cells that are not lymphoblasts) are found in the bone marrow and blood. Also called acute myeloblastic leukemia, acute myelogenous leukemia, acute nonlymphocytic leukemia, AML, and ANLL.• Blood- A tissue with red blood cells, white blood cells, platelets, and other substances suspended in fluid called plasma. Blood takes oxygen and nutrients to the tissues, and carries away waste.• Bone marrow- The soft, sponge-like tissue in the center of most bones. It produces white blood cells, red blood cells, and platelets.• Bone marrow infiltration- Anemia characterized by appearance of immature myeloid and nucleated erythrocytes in the peripheral blood, resulting from infiltration of the bone marrow by foreign or abnormal tissue.• Metastasis- The process by which cancer spreads from the place at which it first arose as a primary tumor to distant locations in the body.• Hemostasis- The stoppage of bleeding or hemorrhage. Also, the stoppage of blood flow through a blood vessel or organ of the body.• Susceptability- is our inherited and aquired predispositions to illness, whether it be physical, mental/emotional or both.• Neutropenia- is a condition in which the number of neutrophils in the bloodstream is decreased.
12 CHAPTER II PRESENTATION, ANALYSIS AND INTERPRETATIONS OF DATAClient profile Patient JA, 2 years and 9 months old male Filipino, Roman Catholic, wasborn on September 21, 2006 and from Babag 1, Lahug, Cebu City.Past Medical History When the client is only 4 months old, sought consultation at BaranggayHealth Unit together with his mother because of convulsion and productivecough (color: whitish-green Texture: sticky). His previous hospitalization was onMay 9, 2009, patient was admitted at Visayas Community Hospital withcomplaints of cough and fever. Persistence of symptoms; was referred andreadmitted at Perpetual Succour Hospital last May 29, 2009 for blood dyscrasia.Confined at PSH-2B room 236, and was diagnosed of having Acute MyelocyticLeukemia last June 2, 2009 by Dr. Maglana.History of Present Illness 1 day PTA at around 4am, pt. experienced an onset of fever 38.9ºC peraxilla, given calpol prn, for fever with temporary temperature relief asssociatedwith productive cough. Persistence of on and off fever, thus pt sought admissionat PSH.
13Environmental History The patients mother description of their place was “ kinababwan sa bukidamo dai, ubos sa tower”, peaceful, having a good relationship with the nearestneighborhood. Their means of lightning is lamp and their means of fire ischarcoal, there is only one window , one room, their water resources is fromnature which they called “tubod”, they have no domestic animal , their toiletingis a matter of open-pit privy or sometimes, went to neighborhood to pee. Theirdrainage system is an open-drainage and their garbage disposal is either buriedor burned. They make used of available source of medication which was someherbal medicine such as “ gabon , bayabas, atis, malungay, ampalaya , tuba-tuba, oregano and mangagaw” . They also make used of some immediate overthe counter drugs such as “calpol or paracetamol biogesic for kids” only if thereis free sample given by the barangay. As stated by his mother.Developmental History The patient is physically fit. He is a healthy child since he was born. Butwhen the time came that he has this kind of illness, he losses wt. (from 15.5kgto 12kg.) and become weak. His father stated that early as 1yr old he had histoilet-training already. Before sleeping, he urinates first to avoid urinating in thebed. And his father stated that James loves to play outdoor games like basketballtogether with his kuya and friends.
14 GORDON’S FUNCTIONAL HEALTH PATTERN1. Health Perception Health Management Patient’s mother perceived her son to be a very active and healthy baby(4 months after delivery), she rates it 9/10 despite of the occurrence of somedisease such as cough and fever. A month prior to admission, parient’s motherperceived her son to be unhealthy, weak and rates her son 6/10(10 as thehighest and 1 as the lowest), it got easily ill. Patient’s mother perceived her sonto be very sickly and rated it 5/10. His parents doesn’t know much of his illnessand verbalizes that “ambot nikalit raman gud ni siya, luya siya tan.awn permenteog manluspad.” Everytime their son get sick they make used of available source ofmedication which was some herbal medicine such as “gabon , bayabas, atis,malungay, ampalaya , tuba-tuba and mangagaw” . They also make used of someimmediate over the counter drugs such as “calpol or paracetamol biogesic forkids” only if there is free sample given by the baranggay, as stated by hismother. They seldomly went to their Baranggay health center because ofinsufficient facilities, unavailable drugs and Physician. They maintain a simpleliving in their barrio and sought help to their nearby neighborhood and runthrough “faith-healer/quack doctor” easily.2. Nutritional Metabolic Last 24 hours prior to admission, patient ate ¼ cup of rice,a bite ofchicken meat and 2tablespoon of vegetable soup. Before hospitalization,patients mother regularly prepares his breakfast meal consisting of ½ glass ofmilk (bear brand), 1 cup of rice, 2 hot dogs, 1 cup of noodles and a half glass ofwater. During lunch, his mother regularly prepares ½ cup of rice,i small plate of
15“pancit” ,a ½ slice of fish meat and 1/2cup of water/juice. During dinner time, ½cup of rice,1 hardboiled egg, small meat of chicken and ½ cup of water.Intervals of each meal, comprise of 1biscuit / 1 regular size of bread with ½glass of carbonated drink/juice/water. During the occurrence of his illness, patient ate: ½ cup of rice with 4tablespoon of vegetable soup on it, ¼ serving of vegetable dish, a bite of hotdog and ½ cup of milk, as his breakfast. Lunchtime meal comprise of; ½ cup ofrice ,vegetable dish, sliced of fish and a ¼ cup of juice/milk. Dinnertime mealcomprise of; ½ cup of rice, a bite of fish meat with vegetable on it, ½ cup ofjuice and a sip of water. Each meal interval,comprise of: a bite of bread(depending on patients appetite to eat and wish to eat) a sip of water or milk, ashis snack. But this seldomly happen according to patients mother. The patientdoesn’t have any vitamins due to financial problems. He doesn’t have anyallergies (foods, meds.). The patient is weighing 12kg. Differential of 15.5kg.3. Elimination Before the onset of disease, patients voids at a regular rate of 6-10x/day,aromatic, amber in color amounting of 1/8-1/4 glass level/void. He defecates1-2x/day, brown in color, soft in consistency, pungent odor. During the onset of disease, patient voids 5-6x/day, amber in coloramounting 1/8glass level/void. He defecates every other day. He doesnt takingany laxatives or suppositories. Before, he sweats around ¼ glass/day, today, hesweats seldomly according to his mother. The patient doesn’t use any diaper forhim to voids and defecates. He used the toilet with assistance.
164. Activity Exercise Before the onset of disease, according to his mother, the patient is fond ofplaying with his older brother “pusil2x”, “Tagu2x”, “Bala2x” and “dakop2x”. Andalso a fond of playing basketball with his kuya and friends. But today, heseldomly play those kind of games because of his present situation where hegets easily tired and weak. Their only fond now of hand plays such as “sikop2x”,“pusil2x”, image forming shadows and art work.5. Sleep-Rest Before the onset of disease, according to his mother, the patients regularsleep timing is 8:00pm and wake-up at 7:00am. But upon admission, thepatients usual sleeping pattern was altered because of some unexpectedawakening activities in the hospital and sometimes because of patientsunhealthy condition.6. Cognitive-Perceptual The patient is only 2 years old. Upon assessment, he can able identifythings and person at his level, he wanted to be with his mother and fatheralways and wanted only to used his own spoon and plate. This best describedthe nonoperational thought stage theory of Piagets sensory motor stage,wherein toddlers recognize that they are separate beings by their mothers, butthey are unable to assume the view of another. They used symbols to representobjects, place, and persons. When pt. JA and I play his toy which is the “turtle”,I asked him like wheres your eyes, mouth, arms, etc. and he was able to answerit well. But when it comes to colors, he cant identify if what color it is.
177. Sexuality Reproductive At the age of two, patient is still uncircumcised and the focus of pleasurechanges to the anal zone. Children became increasingly aware of the pleasuresensations of this body region with interest to the products of their effort.Through the toilet-training process the child is asked to delay gratification inorder to meet parenteral and societal expectation.8. Self Perception-Self Concept Based on the conducted assessment, the patient was very muchpossessive on the things he thought he owned, and wanted the full attention ofhis parents. Jean Piagets theory of cognitive development period II :preoperational, this is the time when childrens learn to think with the used ofsymbols and mental images. Still, egocentric, the child sees objects and personsfrom only one point of view, the childs own.9. Role Relationship Patient JA belongs to a simple family, having only one brother. His motherwork as and his father also. His role being the youngest child was incorporated,process of communication was directly directed to the recipient. He gavehappiness to the family.GENOGRAM(see appendix C, Figure 2)10. Coping and Stress Tolerance Based on my assessment, despite of the patients anxiety on his situation,he still able to make a smile and with the used of his toys and unlimited supportand love of his parents he can still cope up with his present situation.
1811. Values and Belief He is a Roman Catholic. He used to go to church every sunday with hisfamily. But sometimes, they cant go to church because of its distance from theirhouse. The undeniable belief and faith of his parents made their family ties reallystrong. The families belief that in spite of the turned/out diagnoses of their child,cure will still be achieved. Because of their strong faith in God, miracle is alwaysin their heart.
19 PHYSICAL ASSESSMENTGeneral Appearance (Assessed on June 17, 2009 at 7:00am) Seen patient in bed, awake, conscious, responsive and coherent with asterile mask covering the ¾ of his entire face, coherent, responsive, with anongoing intravenous fluid of D5 IMB 500 ml/hr at 30gtts/min infusing well atright arm. With the following vital sign: T-36.4 ºC, P-116bpm, R-42Cycles/min.INTEGUMENTARY SYSTEM The skin was fair complexion, uniform skin color, dry and warm. The hairwas black and evenly distributed. The scalp was symmetrical, free of lesions;lumps or masses may feel normal, bony prominence on the forehead, no massesor nodules. Nails were pale convex, smooth, in good condition and had acapillary refill test result of less than 3 seconds.HEAD AND NECK Head was normocephalic, round and firm. The face has symmetrical facefeatures, smooth, was able to pop out cheeks with symmetry, smiling andsometimes frowned. The neck was brown and centrally aligned, able to flex,extend, hyperextend and move sideways, and non tender.EYES Eyes were watery, able to blink involuntary, able to move togetherthrough the 6 cardinal fields of gaze.
20EARS Ears were c-shaped, aligned slightly above the outer canthus of the eye,no lesions and non tender. Cerumen was present, light brown and able to hear.NOSE AND SINUS Nose was brown, nares were patent, and non tender. Internal noseappeared clean, septum at midline, sinuses were non tender. Able to smell andidentify correctly what has been smelled.MOUTH AND OROPHARYNX Lips were close symmetrically; dry and pale. Buccal mucosa was pink andfirm; gums were light pink and firm. Teeth were yellowish, in good condition.The tongue was light pink, symmetrical, and able to move without difficulty. Softpalate was light pink and firm.THORAX AND LUNGS The chest was brown, symmetrical; respiration are quite effortless andregular sites and falls in unison w/ respiratory cycle of 42.CARDIAC ASSESSMENT Pulse rate was 116bpm at radial site.ABDOMEN
21 Abdomen was brown, no venous pattern; umbilicus was protruding atmidline, and non tender on palpation.GENITOURINARY-REPRODUCTIVE SYSTEM(NOT ASSESSED)ANUS AND RECTUM(NOT ASSESSED)MUSCULOSKELETAL SYSTEM ROM Upper Extremities- able to move up, down, and sideways withassistance, able to flex and extend without assistance. ROM Lower Extremities- able to flex, extend, move sideways, up, downand rotate without assistance.NEUROLOGIC SYSTEM Patient was conscious, in good mood, speech was clear and coherent,able to hear, smell, taste and understand commands.
22 HUMAN ANATOMY AND PHYSIOLOGY Humans cant live without blood. Without blood, the bodys organscouldnt get the oxygen and nutrients they need to survive, we couldnt keepwarm or cool off, fight infections, or get rid of our own waste products. Withoutenough blood, wed weaken and die. Red blood cells (also called erythrocytes) are shaped like slightlyindented, flattened disks. RBCs contain the iron-rich protein hemoglobin. Bloodgets its bright red color when hemoglobin picks up oxygen in the lungs. As theblood travels through the body, the hemoglobin releases oxygen to the tissues.The body contains more RBCs than any other type of cell, and each has a lifespan of about 4 months. Each day, the body produces new red blood cells toreplace those that die or are lost from the body.Red Blood Cells (erythrocytes)The most numerous type in the blood. • Women average about 4.8 million of these cells per cubic millimeter (mm3; which is the same as a microliter [µl]) of blood. • Men average about 5.4 x 106 per µl. • These values can vary over quite a range depending on such factors as health and altitude. (Peruvians living at 18,000 feet may have as many as 8.3 x 106 RBCs per µl.)RBC precursors mature in the bone marrow closely attached to a macrophage. • They manufacture hemoglobin until it accounts for some 90% of the dry weight of the cell.
23 • The nucleus is squeezed out of the cell and is ingested by the macrophage. • No-longer-needed proteins are expelled from the cell in vesicles called exosomes. Thus, RBCs are terminally differentiated; that is, they can never divide. Theylive about 120 days and then are ingested by phagocytic cells in the liver andspleen. Most of the iron in their hemoglobin is reclaimed for reuse. Theremainder of the heme portion of the molecule is degraded into bile pigmentsand excreted by the liver. Some 3 million RBCs die and are scavenged by theliver each second.Red blood cells are responsible for the transport of oxygen and carbon dioxide.Oxygen TransportIn adult humans the hemoglobin (Hb) molecule • consists of four polypeptides: • two alpha (α) chains of 141 amino acids and • two beta (β) chains of 146 amino acids • Each of these is attached the prosthetic group heme. • There is one atom of iron at the center of each heme. • One molecule of oxygen can bind to each heme.The reaction is reversible. • Under the conditions of lower temperature, higher pH, and increased oxygen pressure in the capillaries of the lungs, the reaction proceeds to the right. The purple-red deoxygenated hemoglobin of the venous blood becomes the bright-red oxyhemoglobin of the arterial blood. • Under the conditions of higher temperature, lower pH, and lower oxygen pressure in the tissues, the reverse reaction is promoted and oxyhemoglobin gives up its oxygen. Carbon Dioxide Transport95% of the CO2 generated in the tissues is carried in the red blood cells:
24 • It probably enters (and leaves) the cell by diffusion through the plasma membrane assisted by facilitated diffusion through transmembrane channels in the plasma membrane. (One of the proteins that forms the channel is the D antigen that is the most important factor in the Rh system of blood groups.) • Once inside, about one-half of the CO2 is directly bound to hemoglobin (at a site different from the one that binds oxygen). • The rest is converted — following the equation above — by the enzyme carbonic anhydrase into • bicarbonate ions that diffuse back out into the plasma and • hydrogen ions (H+) that bind to the protein portion of the hemoglobin (thus having no effect on pH). Only about 5% of the CO2 generated in the tissues dissolves directly inthe plasma. (A good thing, too: if all the CO2 we make were carried this way,the pH of the blood would drop from its normal 7.4 to an instantly-fatal 4.5)When the red cells reach the lungs, these reactions are reversed and CO2 isreleased to the air of the alveoli. White blood cells (also called leukocytes) are a key part of the bodyssystem for defending itself against infection. They can move in and out of thebloodstream to reach affected tissues. The blood contains far fewer WBCs thanred cells, although the body can increase production of WBCs to fight infection.There are several types of WBCs, and their life spans vary from a few days tomonths. New cells are constantly being formed in the bone marrow. Several different parts of blood are involved in fighting infection. Whiteblood cells called granulocytes and lymphocytes travel along the walls of bloodvessels. They fight germs such as bacteria and viruses and may also attempt todestroy cells that have become infected or have changed into cancer cells.
25 Certain types of WBCs produce antibodies, special proteins that recognizeforeign materials and help the body destroy or neutralize them. The white cellcount (the number of cells in a given amount of blood) in someone with aninfection often is higher than usual because more WBCs are being produced orare entering the bloodstream to battle the infection. After the body has beenchallenged by some infections, lymphocytes "remember" how to make thespecific antibodies that will quickly attack the same germ if it enters the bodyagain.White Blood Cells (leukocytes) • are much less numerous than red (the ratio between the two is around 1:700); • have nuclei; • participate in protecting the body from infection; • consist of lymphocytes and monocytes with relatively clear cytoplasm, and three types of granulocytes, whose cytoplasm is filled with granules.Lymphocytes There are several kinds of lymphocytes (although they all look alike underthe microscope), each with different functions to perform. The most commontypes of lymphocytes are • B lymphocytes ("B cells"). These are responsible for making antibodies. • T lymphocytes ("T cells"). There are several subsets of these: • inflammatory T cells that recruit macrophages and neutrophils to the site of infection or other tissue damage • cytotoxic T lymphocytes (CTLs) that kill virus-infected and, perhaps, tumor cells • helper T cells that enhance the production of antibodies by B cells Although bone marrow is the ultimate source of lymphocytes, thelymphocytes that will become T cells migrate from the bone marrow to thethymus where they mature. Both B cells and T cells also take up residence inlymph nodes, the spleen and other tissues where they
26 • encounter antigens; • continue to divide by mitosis; • mature into fully functional cells.Monocytes A white blood cell that has a single nucleus and can ingest (take in)foreign material. In other words, a monocyte is thus a mononuclear phagocytethat circulates in the blood. Monocytes later emigrate from blood into the tissuesof the body and there differentiate (evolve into) into cells called macrophageswhich play an important role in killing of some bacteria, protozoa, and tumorcells, release substances that stimulate other cells of the immune system, andare involved in antigen presentation.Macrophages are large, phagocytic cells that engulf • foreign material (antigens) that enter the body • dead and dying cells of the body.Neutrophils The most abundant of the WBCs. Neutrophils squeeze through thecapillary walls and into infected tissue where they kill the invaders (e.g.,bacteria) and then engulf the remnants by phagocytosis.This is a never-ending task, even in healthy people: Our throat, nasal passages,and colon harbor vast numbers of bacteria. Most of these are commensals, anddo us no harm. But that is because neutrophils keep them in check.However,heavy doses of radiation, chemotherapy, and many other forms ofstress can reduce the numbers of neutrophils so that formerly harmless bacteriabegin to proliferate. The resulting opportunistic infection can be life-threatening.Eosinophils The number of eosinophils in the blood is normally quite low (0–450/µl).However, their numbers increase sharply in certain diseases, especially infectionsby parasitic worms. Eosinophils are cytotoxic, releasing the contents of theirgranules on the invader.
27Basophils The number of basophils also increases during infection. Basophils leave theblood and accumulate at the site of infection or other inflammation. There theydischarge the contents of their granules, releasing a variety of mediators suchas: • histamine • serotonin • prostaglandins and leukotrieneswhich increase the blood flow to the area and in other ways add to theinflammatory process. The mediators released by basophils also play animportant part in some allergic responses such as • hay fever and • An anaphylactic response to insect stings. •PlateletsPlatelets are cell fragments produced from megakaryocytes.Blood normally contains 150,000–400,000 per microliter (µl) or cubic millimeter(mm3). This number is normally maintained by a homeostatic (negative-feedback) mechanism.If this value should drop much below 20,000/µl, there is a danger of uncontrolledbleeding.Some causes: • certain drugs and herbal remedies; • autoimmunity. When blood vessels are cut or damaged, the loss of blood from the systemmust be stopped before shock and possible death occur. This is accomplished bysolidification of the blood, a process called coagulation or clotting.A blood clot consists of • a plug of platelets enmeshed in a
28 • network of insoluble fibrin molecules.PlasmaPlasma is the straw-colored liquid in which the blood cells are suspended.Composition of blood plasma COMPONENTS PERCENT Water ~92 Proteins 6–8 Salts 0.8 Lipids 0.6 Glucose (blood 0.1 sugar)Plasma transports materials needed by cells and materials that must be removedfrom cells: • various ions (Na+, Ca2+, HCO3−, etc.) • glucose and traces of other sugars • amino acids • other organic acids • cholesterol and other lipids • hormones • urea and other wastesMost of these materials are in transmit from a place where they are added to theblood (a "source") • exchange organs like the intestine • depots of materials like the liverto places ("sinks") where they will be removed from the blood. • every cell • exchange organs like the kidney, and skin
29 DIAGNOSTIC EXAM URINALYSIS is an array of tests performed on urine and one of the mostcommon methods of medical diagnosis. A part of a urinalysis can be performedby using urine dipsticks, in which the test results can be read as color changes. EXAM DESCRIPTION INTERPRETATION Ionized Used to monitor Ca levels Normal calcium during and after large volume of blood transfusions. SGPT/ALT Injury or disease affecting An increased level of SGPT occurs the liver parenchyma will when there is cause a release of this • Hepatitis hepatocellular enzyme into • Hepatic necrosis the blood stream, thus elevating serum ALT levels LDH Widely distributed through An increased level of LDH when the body, the total LDH there is level is not a specific • Leukemia indicator of any one organ • Or other particular types of cancer or diseases ALP is a hydrolase enzyme Adults have lower levels of ALP than responsible for removing phosphate groups from children because childrens bones many types of molecules, are still growing. During some including nucleotides, growth spurts, levels can be as proteins, and alkaloids. The high as 500 IU/L. Usually children process of removing the are not measured because of the phosphate group is called potential for such high amounts,
30 dephosphorylation. so the abnormal results refer to adults. BUN Measures the amount of normal urea nitrogen in the blood. Is formed in the liver as the end product of protein metabolism Creatinine Creatinine is a catabolic normal product of creatinine phosphate, which is used in skeletal muscle contraction. Sodium Determines the amount of normal sodium excreted in urine over 24hrs. Potassium Acid-based balance is normal dependent on potassium excretion to a small degree. COMPLETE BLOOD COUNT is a test requested by a doctor or othermedical professional that gives information about the cells in a patients blood. Ascientist or lab technician performs the requested testing and provides therequesting Medical Professional with the results of the CBC. EXAM DESCRIPTION INTERPRETATION WBC WBC is to fight infection and A decreased total WBC count react against foreign bodies occurs in many form, of tissues overwhelming infection, and autoimmune disease.
31Neutro- A defend against bacterial Any deceased neutrophilphil or fungal infection and • Overwhelming of other very small bacterial infection inflammatory processes that are usually first responders to microbial infection; their activity and death in large numbers forms pus.lymphocytes Lymphocytes are • Immunodeficiency distinguished by having a disease deeply staining nucleus • leukemia which may be eccentric in location, and a relatively small amount of cytoplasm.Monocytes Phagocytic cells capable of • monocytopenia fighting bacteria in a way very similar to that of neutrophilsEosinophil deals with parasitic • eosinopenia infections and an increase in them may indicate such. Eosinophils are also the predominant inflammatory cells in allergic reactions.Basophil Basophil/mast cell capable • Basopenia of phagocytosis of antigen- • Acute antibody complexes. responsible for allergic and • allergic reaction antigen response by • Stress reaction releasing the chemical
32 histamine causing inflammation.Hemoglobin( Measure of the total amount Decreased Hgb levelHgb) of hemoglobin in the • anemia peripheral blood, which reflects the numbers of RBCs in the blood.Hematocrit( Measure of the percentage Decreased hematocrit levelHct) of the total blood volume • Anemia that is made up by the RBCs • Malnutrition • LeukemiaRBC RBC count is routinely A decrease RBC level Signifies performed as part of a Anemia complete blood count. Where molecules of hemoglobin that permit the transport and exchange of oxygen to the tissues and carbon dioxide from the tissuesPlatelet It is used to monitor the Decreases platelet count occurscount course of the disease when there is • leukemia • and other myelofibrosis disorder Pathophysiology
33Host Agent Environment>Male Continues division of cells>2yrs old excessive leukocyte precursor growth Crowd out the normal marrow Accumulation of immature cells Impaired bone marrow function Bone infiltration Bone joint pain Neutropenia Thrombocytopenia Anemia Increased infection impaired hemostasis Susceptability Increased bleeding hypovolemia Metastasis( dec. Blood circulation)Crowd out cellular proliferation Of other cell Liver SpleenLymph nodes Hepatomegaly Splenomegaly LymphadenopathyErythrocytic Megakaryotic stem cellsstem cells immature WBCDecrease RBC Decrease platelet Non-functional cells
34 Decrease defense against infectionAnemia Bleeding Increased vulnerability to infection *fever sepsis DEATH NURSING CARE PLAN
35Name of Patient: JA Sex: MaleAge: 2years old NURSING NURSING INERVENTION EVALUATION DIAGNOSIS/ CUESAltered 1.Identify underlying cause After nursingthermoregulation *to determine its appropriate intervention herelated to ongoing treatment. patient was able toinfection 2.Monitored core temperature maintain a coreObjective Cue: *to assess changes of temperature. temperature within-WBC-1.34x10/L 3. Performed tepid sponge bath normal range.-Unstable body *to decrease body temperature.temp 4.Noted presence or absence of-intermittent fever sweating-temp: 36.4 ºC *to prevent dehydration.-weak 5. Maintained bed rest *to promote wellness. 6.Administered antipyretic as prescribed by the doctor *to maintain gains and continue progress if able. 7.Administered replacement fluid and electrolytes as prescribed *to correct fluid and electrolytes imbalance. 8. Discussed to the patient together with the SO the importance of adequate fluid intake. *to provide facts about appropriate
36 treatment.Risk for injury 1.Established rapport After nursingrelated to *to promote good communication. intervention theabnormal blood 2.Kept sharp objects away from the patient together withprofile secondary patient the SO was able toto *to promote safe physical demonstratethrombocytopenia environment and individual safety. behaviours to reduce 3.Instructed the SO to have a risk factors andSubjective Cue: watcher to the patient protect self from........ *to avoid further injury. injury. 4.Raised side railsObjective Cue: * to prevent from injury.Platelet= 5.Kept the floor dry131x10º/L *to avoid injury and promote-fatigue safety.-weakImbalanced 1. Assessed for factors contributing After nursingNutrition: less to altered nutritional intake. intervention thethab body *Information about other factors patient together withrequirements that may be altered or eliminated to the SO was able torelated to promote adequate dietary intake is stimulate his appetite.anorexia and provided.altered oral 2. Provide patient’s foodmucous preferences within dietarymembrane restrictions. *Increased dietary intake isSubjective Cue: encouraged.“Dakoon ni siya 3. Provide pleasant surroundings atsauna karon meal times.
37nagniwang na *to enhance intake.tungod sa iyang 4. Prevent unpleasant odors/sights.sakit”, as *may have a negative effect onverbalized by the appetite/eating.mother. 5. Encourage client to choose foods/have family member bringObjective Cue: foods that seem appealing.-loss of appetite *to stimulate appetite.-stated weightloss(12kg. From15.5kg)-eating loss-paleDisturbed body 1. Encourage client to look and After nursingimage: hair loss touch affected body part. intervention therelated to post *to begin to incorporate changes patient together withchemo status. into body image. the SO was able to 2. Encourage client for verbalize adaptationSubjective Cue: verbalization. to actual or altered“nanglarut iya *to enhance handling of potential body image.buhok pero situations.ginagmay ra” as 3. Instruct patient significant othersverbalized by the to purchase a wig or hats.mother. *to enhance appearanceObjective Cue: 4.Instruct to put up on sunscreen
38-hair loss *to prevent sunburns since patient-pale has sensitive skull-weak 5. Comfort patient in knowing that his hair will grow back *to enhance self confidence.Deficient 1. Determine pt. /S.O perception of After nursingKnowledge cause of AML. intervention theregarding disease *Establishes knowledge base and patient together withprocess related to provides some insight info. How the the SO was able tolack of teaching plan needs to be verbalizeinformation. constructed for this individual. understanding of 2. Provide/review info. Regarding cause of AML,Subjective Cue: etiology of AML cause/effect, treatment modalities“ambot nikalit relationship of lifestyle behaviours and identify/raman gud ni and ways to reduce risk/ implement necessarysiya, luya siya contributing factors. lifestyle changes.tan.awn permente *provides knowledge base fromog manluspad”, which pt. /S.O can make informedas verbalized by choices/decisions about future andthe mother. control of health problems. 3. Instruct pt. / S.O to use mask or protective equipments. *reducing spread of infection. 4. Refer to support groups/ counselling for lifestyle/behaviour changes, reduction of associated risk factors. *for proper management.
39 CHAPTER III SUMMARY OF FINDINGS, PROGNOSIS, RECOMMENDATIONS/DISCHARGE PLANSUMMARY OF FINDINGS Health was defined as being defined as "a state of complete physical,mental, and social well-being and not merely the absence of disease orinfirmity". But one of the most difficult life changes which we will face is whenone of the family members is being ill or was diagnosed with terminal illness.During this problem, it is important to have a friend or a family member who willsupport you and give you strength. Of course the nurse plays the most vital rolein caring. The nurse must give care to the patient holistically and not just curingthe disease. Caring must involve the physical, psychological, social, emotionaland spiritual aspect of the person. The purpose of this study is to be aware of the different manifestationsof the disease, the precipitating factors that led for the patient to acquire thedisease, the different signs and symptoms of Acute Myelocytic Leukemia, thenursing diagnoses formulated for the disease and the interventions provided tothe patient in response to the diagnoses formulated. Different pharmacologic and nursing management were done to thepatient. The medications given were clarythromycin and paracetamol.Clarithromycin is useful in acute worsening of chronic bronchitis, communityacquired pneumonia. And also used to treat uncomplicated skin and skinstructure infections. Paracetamol for the relief of mild to moderate pain, fever,migraine, tension, headaches Nursing management includes action interventions such as passive, ROMexercises and assistance in performance of his ADLs. Intervention in theenvironment was also done such as keeping the room quiet and cool, and limitsvisiting hours.
40PROGNOSIS Acute Myeloid Leukemia can be controlled and sometimes cured. Itsprognosis depends on a variety. AML can be kept in remission for a long period of time or even cured insome adults. Depending on certain factors such as, the characteristics of theleukemia cells. Some patients have a better prognosis in comparison to others.RECOMMENDATIONS Based on findings and conclusions made, the researchers advance thefollowing recommendations: 1. That this research may be implemented for the people to further understand the disease process of Acute Myelocytic Leukemia. 2. Propose a guideline to prevent the disease or to lessen the manifestations of the disease process.
41 DISCHARGE PLAN Objectives Nursing interventionBy the time the patient will bedischarged on the hospital, he will beable to:M- Take home meds. ♥ To explain to the pt. and to his S.O the prescribed medications with their nature and effects. *Clarythromycin - macrolides -125/5 4ml –P.O B.I.D *Paracetamol -Nonopioid analgesics and antipyretics -250/5ml, 4ml every 4hrs prnE- Maintain a safe environment. ♥ Instruct the mother/ s.o to prepare foods that is not contaminated with infectious agents. ♥ Demonstrate proper handwashing. -wet hands with uncontaminated water
42 -apply soap -rub hands together, interlacing each finger -rinse hands -dry hand thoroughly using clean cloth *Handwashing should be done during food prep. And after using the toilet to avoid spreading of microorganism.-Keep a clean and well sanitized ♥ Emphasize to the s.o of the pt.environment the importance of maintaining a clean and well sanitized environment to prevent from acquiring microorganism that could alter their health status.T-Continuing the appropriate ♥ Encourage pt and his family thetreatments and follow-up check-up importance of having follow-up check-up and continuous of the appropriate treatments.H- Discuss the importance/ factors that ♥ Explain to the pt. and his familytend toward the cause and effects of the importance/ risk factors thathis disease lead to the existence of his disease (AML (Acute Myelocytic Leukemia) is a cancer that starts in cells that would normally develop into different types of
43 blood cells. Most cases of AML develop from cells that would turn into white blood cells (other than lymphocytes), but some cases of AML develop in other types of blood-forming cells. AML starts in the bone marrow (the soft inner part of the bones, where new blood cells are made), but in most cases it quickly moves into the blood. It can sometimes spread to other parts of the body including the lymph nodes, liver, spleen, central nervous system (brain and spinal cord), and testes. )O-Observe the signs and symptoms of ♥ Explain to the pt. and his familythe disease the signs and symptoms of the disease - Tiredness or no energy -Shortness of breath during physical activity -Pale skin -Swollen gums -Slow healing of cuts -Pinhead-size red spots under the skin -Prolonged bleeding from minor cuts -Mild fever -Black-and-blue marks (bruises) with no clear cause -Aches in bones or knees, hips or
44 shoulder.D-Identify the appropriate diet towards ♥ Encourage the pt. & S.O to eatthe recovery of the pt. nutritious foods that is good for health like eating vegetables(squash,green-leafy vegetables,etc.) and fruits(orange,apple,grapes,etc)S- Improve spiritual well being towards ♥ Encourage the pt. and his familypersonal beliefs and values to acquire spiritual growth and beliefs(attending masses every Sunday,praying novena).
47 Appendix A COMPLETE BLOOD COUNT TEST RESULT NORMAL RANGE WBC 1.34 4,500-11,000/mm3Neutrophils 7 40-75%(2,500-7,500/mm 3)Lymphocytes 0 20-50%(1,500-5,500/mm 3) Monocytes 1 1-10%(100-800/mm3)Eosinophils 0 0-6%(0-440/mm3) Basophils 0 0-2%(0-200/mm3)Hemoglobin 8.9 M: 13.5-17.5 g/dl F: 11.5-15.5 g/dlHematocrit 24.8 M: 40-52% F: 36-48% RBC 4.2 M: 4.7-6.1x10.6/uL F: 4.2-5.4x10.6/uL Platelet 131x10º/L 150-400x10º/L
48 URINALYSIS TEST RESULT NORMAL RANGEIonized calcium 1.25mmol/L 1.20-1.38mmol/L SGPT/ALT 67.00 U/L 4-36 U/L LDH 1061.9 U/L 0 - 250 U/L ALP 192.874IU/L 20 to 140 IU/L BUN 3.93mmol/L 1.7-8.3mmol/L Creatinine 30.06mmol/L 53.04-132.6mmol/L Sodium 136mmol/L 40-220mmol/L Potassium 3.88mmol/L 3.4-5.2mmol/L Appendix B
49 DRUG STUDYA case of 2 year DRUG NAME OF old, INDICATIONS SIDE EFFECTSmale patientdiagnosed withAcute Myelocytic clarithromycin Clarithromycin is useful in • HeadacheLeukemia. (Biaxin) acute worsening of chronic • Diarrhea bronchitis, community • AbdominalHe complained of Anti-infectives acquired pneumonia. And pain orpersistent on and off also used to treat discomfortfever, and cough uncomplicated skin and skin • Nauseathus prompted his structure infections. • vomitingadmission. • rashHe has no knownheredo-familialdisease. acetaminophen for the relief of mild to Side effects of (Paracetamol) moderate pain, fever, paracetamol are migraine, tension, rare. Uncommon analgesic, antipyretic headaches side effects include indigestion, nausea, rashes. Flow of the Study Input Throughput/Process Output
50 Management Recommendations: • Medical The patient/S.O is Figure 1 Management advised to always Schematic Diagram • Pharmacological maintain a clean Appendix C Treatment environment, limit Appendix C visitors, and do ROM Figure 2 exercises and assistance in performance ofGENOGRAM: patient’s activities of daily living. Prognosis: Legend: Good- if treated -Female immediately with DM - Diabetes chemotherapy andMellitus medical mgt. Poor- if untreated immediately, it would lead to sepsis then eventually death. - Male HPN - Hypertension - Patient(male) A - Asthma † - Died AML -Acute Myelocytic Leukemia HP DM A N