Oncology Coursework

In Partial Fulfillment of the Requirements for the Subject

AAN202 ONCOLOGY NURSING

for the degree Master of Science in Nursing – Adult Health

Submitted to:

Mrs. Catherine Liban-Versoza, MSN

SPUP Graduate School Faculty

Submitted by:

Wella Joy Panopio Diola, RN

SPUP MSN 2019 Student

1st Trimester 2019

 TABLE OF CONTENTS

TABLE OF CONTENTS ............................................................................................................................. i

I. Individual Case Study ......................................................................................................................... 1
A. Patient’s Profile ......................................................................................................................... 1
B. Brief Discussion of the case ....................................................................................................... 6
C. Nursing Assessment (Gordon’s Functional Assessment) ......................................................... 12
D. Anatomy and Physiology ......................................................................................................... 14
E. Pathophysiology...................................................................................................................... 20
F. Diagnostic/Laboratory Exams ................................................................................................. 36
G. NURSING CARE PLAN .............................................................................................................. 51
H. DRUG STUDY ........................................................................................................................... 65
II. Program Proposal on Cancer Prevention and Control .................................................................... 72
I. Project Title: Leukemia Awareness and Prevention Program ................................................. 72
A. Rationale ............................................................................................................................. 72
B. Objectives: Prevention, Early Detection, Early Diagnosis and Early Treatment................... 72
C. Content ............................................................................................................................... 73
D. Methodology....................................................................................................................... 73
E. Operating details ................................................................................................................. 73
III. Research Article and Critique ......................................................................................................... 80
A. Article ...................................................................................................................................... 81
B. Critique ................................................................................................................................... 91
References: ......................................................................................................................................... 94

i|P age
ii | P a g e
I. Individual Case Study

A. Patient’s Profile
a. General Information

NAME: Mila Gonzalo Panopio

DATE OF BIRTH: September 14, 1958
AGE: 60
SEX: Female
ADDRESS: Binondo, Manila
BIRTH PLACE: Bago City, Negros Occidental
NATIONALITY: Filipino
RELIGION: Roman Catholic
CIVIL STATUS: Married
OCCUPATION: Housewife
COMPLAINTS: Fever, difficulty swallowing, swollen lymph nodes
DIAGNOSIS: Acute Myelogenous Leukemia
PHYSICIAN: Dr. Angelina Mirasol
HOSPITAL: Philippine General Hospital – Pay Department

b. Family and Individual Information, Social and Health History

Patient is a 60 year old female who is married and has three children, two of which
are already working and the youngest is still schooling. The patient is a housewife with no
reported exposure to chemical products other than household cleaning products. She
reported no family history of Cancer. She is hypertensive controlled with oral
antihypertensive drug, with previous case of gastric esophageal reflux disorder, with three
caesarian sections delivery in 1984, 1987 and 2000, post-surgical removal of a benign cyst in
her breast in 2010 and post internal fixation surgery of fracture in her right foot in 2011. She
has hypersensitivity to aspirin. She was initially admitted in the Emergency Department of
Justice Jose Abad Santos General Hospital in February 19, 2019 due to severe pallor, loss of
appetite, generalized body weakness, difficulty of swallowing, nausea and vomiting prior to
being diagnose with AML with CBC of Hgb 60, WBC 49.3 and Plt 131. 3 bags of PRBC were
transfused and still with abnormal CBC of Hgb 90, WBC 35.6 and Plt 75. Patient was discharged
in February 24, 2019 and referred to Hematologist. The patient was seen and examined by
Dr. Laurence Morillo in February 26, 2019; hematologist in University of Sto. Tomas Hospital
with recommendation to do bone marrow aspiration biopsy. Patient seek second opinion with
Dr. Angelina Mirasol Hematologist in Philippine General Hospital in March 2, 2019 and was
directly admitted with CBC of Hgb 85, WBC 21, Plt 72, monocyte 0.50, blast 0.29 and reactive

1|P age
lymphocyte of 0.01. Bone marrow aspiration done, specimen sent for flow cytometry in
National Kidney and Transplant Institute and bone marrow biopsy. Flow cytometry result
came in negative while final histopathologic findings consistent with involvement by acute
myelogenous leukemia. Bone marrow specimen was later on sent for multiple
immunohistochemistry staining while patient is continuously admitted in PGH for supportive
care while waiting for immunohistochemistry result. She was rushed in PGH ER Department
in May 21, 2019 with final diagnosis of Tumor Lysis Syndrome; AKI prob pre-renal from
hypoperfusion, bicytopenia with hyperleukocytosis from AML. Patient has Creatinine level of
526, BUN 26, BUA 1.346, ALB 39, Na 133, K 3.8 Phos 2.57, Ca 1.83, CBC of Hgb 65, WBC 255,
Plt 58. Patient received multiple blood transfusions of both leukodepleted PRBC and platelet,
hydroxyurea given TID for management of hyperleukocytosis, Fluconazole for treatment of
oral thrush and levofloxacin as prophylactic antibiotic. Sevelamer, oral Sodium Bicarbonate,
Potassium Citrate, Calcium Gluconate, Trimagnesium and Febuxostat for management of AKI.
Patient discharge with improved condition and normal CBC and Kidney profile. Readmitted in
PGH in June 15, 2019 for supportive blood transfusion and discharge in June 18.
Immunohistochemistry result released on July 2, 2019 with final histopathologic diagnosis of
acute myelogenous leukemia MPO and CD45 positive. Patient was recommended to undergo
low dose chemotherapy to control cancer cells plus supportive care. Patient has improved
status in the period of July until early September then admitted in September 6, 2019 with
chief complaint of fever, difficulty swallowing and swollen lymph nodes.

c. Physical Examination

Body Parts Inspection Palpation Percussion Auscultation

Head Round in shape No tenderness
Normocephalic No lumps
Hair Thin unevenly
distributed,
white and black
in color, slightly
curled and short
Scalp No dandruff No lumps
Face Presence of age
spots/pigmented
spots and
wrinkles.
Petechiae seen
in both sides of
cheeks
Forehead Round, brown in No lumps
color
Eyebrows Black in color No lumps

2|P age
 No lesion
Eyelids Closes and open No mass
without difficulty
Eyelashes Equally
distributed
Conjunctiva Pale and moist
Sclera Slightly yellowish
in color and
moist
Pupil Equally round
and reactive to
light and
accommodation.
Constricts and
dilates
Iris Dark brown in
color
Lacrimal Pale, no
discharges
Extraocular eye Moves without
movement difficulty, follows
the six cardinal
gaze
Lips Pale in color, No mass
symmetrical
Mouth Gums are pale, No mass
fair in size and
dry
Tongue Pale pinkish in
color with
presence of milk
like white
discharge (oral
thrush)
Teeth Complete set of
dentures
Palate Slightly pale in
color. White and
red spots

3|P age
 present in upper
palate
Uvula Rises upon
saying “ah”
medially located
Tonsils Pale in color and
swollen
Nose Patent, centrally
located, septum
located medially,
no discharge, no
lesions, no nasal
flaring
Ears Symmetrical, ear
wax noted, can
hear clearly.
Auricle aligned
with outer
canthus
Neck Brown in color, Pain reported
lymph nodes upon palpation.
inflamed Carotid pulse
85 beats per
minute
Skin Pale and slightly
yellowish in
color. Petechiae
was noted in
both upper and
lower
extremities (pin
point like
appearance).
Skin
temperature of
37.8 degrees
Celcius
Extremities:

Upper Can perform

limited ROM

4|P age
 exercise,
petechiae noted
Chest Equal chest Vibration felt
expansion upon tactile

RR: 26 breaths fremitus

per minute
Heart BP 100/60
mmhg
Lungs Clear breath
sounds
Abdomen Pale and slightly No mass Normal Hyperactive
yellowish in bowel sounds
color

No abdominal
distention
Lower Can perform
Extremities limited ROM
exercise,
presence of
petechiae on
both legs

5|P age
 B. Brief Discussion of the case

a. Brief History of Present Illness

3 days PTA (+) epigastric pain, (+) nausea, (+) vomiting, increase frequency of
urination

2 days PTA (+) fever, difficulty swallowing, swollen lymph nodes and loss of appetite

b. Incidence of Type of Cancer in the Philippines

According to the Department of Health (DOH) Leukemia is among the top 5 killer cancers
in the country. The Philippine Cancer Society, for their 2015 Philippine Cancer Facts &
Estimates report, has said that around 4.5 individuals per 100,000 Filipinos will develop the
disease. The same report estimated that around 4,270 new cases were diagnosed for the
year, plus 3,386 leukemia-caused deaths in 2015 as seen in Table 1.

Table 1 shows new cases of Leukemia for both male and female in 2015

6|P age
Table 2 shows estimated leading new cancer cases, both sexes.

7|P age
 Table 3 Estimated leading new cancer cases, Males 2015

Table 3 shows the number of new cases in 2015 among men per cancer site ranked
according to decreasing number of new cases and figure 2 illustrates the top 10 leading sites
with leukemia ranked at number 5.

8|P age
 Table 4 Estimated leading new cancer cases, Female 2015

Table 4 shows the number of new cases in 2015 among women per cancer site, ranked
according to decreasing number of new cases and figure 3 illustrates the top 10 leading sites
wherein Leukemia is ranked at number 9.

9|P age
 Table 5 Estimated Leading New Cancer Deaths, Both Sexes 2015

Table 5 shows the number of new deaths in 2015 among men per cancer site, ranked
according to decreasing number of deaths with the 10 leading sites wherein Leukemia is
ranked at number 5.

Incidence, Mortality and Survival

In 2010, leukemias will rank 7th in both sexes (4%), 5th in males (5%) and 9th among
females (3%). In 2012, the estimated age-standardized national incidence rates of leukemias
were 4.5 per 100,000 in both sexes, 4.8 among males and 4.5 among females. Less than one
(0.4) out of 100 males and less than one (0.4) out of 100 females would have had a likelihood
of getting leukemia before age 75. The estimated national standardized mortality rates were
3.9 per 100,000 in both sexes. 4.1 among males and 3.7 among females. Less than one (0.4)
out of 100 men and less than one (0.3) out of 100 women would have died from leukemia
before age of 75.

In 2015, there will be an estimated 4,270 new cases in both sexes, 2,166 in males and
2,104 in females. There will be 3,386 deaths in both sexes. 1,706 in men and 1,680 in women.

The incidence rate of Myeloid Leukemias is slightly higher than that of Lymphoid
Leukemia. Age-specific incidence rates of Lymphoid Leukemia are highest among children and
people 70 years and older. Age-specific incidence rates of Myeloid Leukemia rise from age 50
years.

10 | P a g e
 For adult Leukemia cancers (both sexes) diagnosed between 1993-2002 and using
population-specific life tables, the 5 year relative survival rate of Metro Manila residents
(5.2%) was lowered compared to Filipino-Americans (37.8%) and Caucasians (48.4%) in the
United States. For leukemia cancers (both sexes) diagnosed between 1995-1999 and also
using population-specific life tables, survival adult Metro Manila residents (2.7%) was also
lower compared to European residents (42.4%) in the Eurocare-4 study. Accessibility to
proper treatment could have been a key factor.

11 | P a g e
C. Nursing Assessment (Gordon’s Functional Assessment)
Health Patterns
Health Perception-Health Management The patient reported no history of cancer
Pattern
Nutritional-Metabolic Patter.
Elimination Pattern
Activity Exercise Pattern
Sleep-rest Pattern
Cognitive-Perceptual Pattern
Assessment
in both sides of her family. Prior to
diagnosis of AML, patient describes herself
as a healthy individual. She doesn’t smoke
nor drink alcoholic beverages with regular
exercise in the form of brisk walking.
She eats a well balance healthy meal with
meat and vegetables but admits to have
fond of drinking carbonated beverages
(soft drinks) every day. Patient’s families
were described as healthy eater except for
her youngest child who is a picky eater.
Patient does not drink water a lot. Patient
is underweighted at 43 kilos and 5’4 ft in
height with BMI of 16.24 underweight
category. Loss of appetite reported prior
to diagnosis of AML.
Patient defines regular bowel elimination
but noted for black tarry stool. Increase in
frequency of urination was also reported.
No pain nor discomfort prior to
elimination were reported.
Patient does regular exercise in the form
of brisk walking. Prior to diagnosis, patient
is known to attend aerobics class every
weekend. Other than exercise, household
chores kept the patient active and moving
every day.
Patient has difficulty performing daily
routine activities due to low hemoglobin.
She describes weakness and shortness of
breath during strenuous activities. She
describes sleeping for a total of 6 hours a
day and waking up in between due to
discomfort.
Patient has no difficulty in hearing but
defines difficulty of seeing and reading
without glasses. Her glasses are graded
12 | P a g e

Self-Perception-Self Concept Pattern
Role-relationship Pattern
Sexuality-Reproductive Pattern
Coping-Stress Tolerance Pattern
Values-Beliefs Pattern
150 both lens. Patient can follow basic and
complex instructions.
Patient shows strong faith in God and
accepts her disease. She admits hope in
getting healed by the grace of God.
Though at times she reports feeling
depress, she describes prayer as her tool
of surviving and getting pass depression.
Patient lives with her husband, brother,
youngest son and nephew. She speaks
Ilonggo and Tagalog fluently. She reported
having good relationship with her family
including her 2 children who are no longer
living with her.
Patient is already menopause and no
longer perform sexual activity.
The patient and her daughter who is a
professional health care provider make
the decision when it comes to health and
financial matters. He sometimes seek help
to her other families and finds comfort in
sharing her feelings with them.
Religion plays an important part of her life.
She attends mass regularly and prays the
rosary every night. For her, God and her
family are her source of strength and
hope. Patient verbalizes acceptance of her
disease and God’s will for her.
13 | P a g e
 D. Anatomy and Physiology

a. Immune System

The immune system is the body's defense against infectious organisms and other
invaders. Through a series of steps called the immune response, the immune system attacks
organisms and substances that invade body systems and cause disease.

The immune system is made up of a network of cells, tissues, and organs that work
together to protect the body. One of the important cells involved are white blood cells, also
called leukocytes, which come in two basic types that combine to seek out and destroy
disease-causing organisms or substances.

14 | P a g e
 A macrophage, in yellow, engulfs and consumes a bacterium. Macrophages are large
phagocytes, cell that wander through the body consuming foreign particles such as dust,
asbestos particles and bacteria. They help protect the body against infection.

White blood cells are the mainstay of the immune system. Some white blood cells,
known as macrophages, play a function in innate immunity by surrounding, ingesting and
destroying invading bacteria and other foreign organisms in a process called phagocytosis
which is part of the inflammatory reaction. Macrophages also play an important role in
adaptive immunity in that they attach to invading antigens and deliver them to be destroyed
by other components of the adaptive immune system

Leukocytes are produced or stored in many locations in the body, including the
thymus, spleen, and bone marrow. For this reason, they're called the lymphoid organs. There
are also clumps of lymphoid tissue throughout the body, primarily as lymph nodes, that house
the leukocytes.

The leukocytes circulate through the body between the organs and nodes via
lymphatic vessels and blood vessels. In this way, the immune system works in a coordinated
manner to monitor the body for germs or substances that might cause problems.

The two basic types of leukocytes are:

• phagocytes, cells that chew up invading organisms

• lymphocytes, cells that allow the body to remember and recognize previous
invaders and help the body destroy them

A number of different cells are considered phagocytes. The most common type is the
neutrophil, which primarily fights bacteria. If doctors are worried about a bacterial infection,
they might order a blood test to see if a patient has an increased number of neutrophils
triggered by the infection. Other types of phagocytes have their own jobs to make sure that
the body responds appropriately to a specific type of invader.

15 | P a g e
 The two kinds of lymphocytes are B lymphocytes and T lymphocytes. Lymphocytes
start out in the bone marrow and either stays there and mature into B cells, or they leave for
the thymus gland, where they mature into T cells. B lymphocytes and T lymphocytes have
separate functions: B lymphocytes are like the body's military intelligence system, seeking out
their targets and sending defenses to lock onto them. T cells are like the soldiers, destroying
the invaders that the intelligence system has identified.

When antigens (foreign substances that invade the body) are detected, several types
of cells work together to recognize them and respond. These cells trigger the B lymphocytes
to produce antibodies, which are specialized proteins that lock onto specific antigens.

Once produced, these antibodies stay in a person's body, so that if his or her immune
system encounters that antigen again, the antibodies are already there to do their job. So if
someone gets sick with a certain disease, like chickenpox, that person usually won't get sick
from it again.

This is also how immunizations prevent certain diseases. An immunization introduces

the body to an antigen in a way that doesn't make someone sick, but does allow the body to
produce antibodies that will then protect the person from future attack by the germ or
substance that produces that particular disease.

Although antibodies can recognize an antigen and lock onto it, they are not capable of
destroying it without help. That's the job of the T cells, which are part of the system that
destroys antigens that have been tagged by antibodies or cells that have been infected or
somehow changed. (Some T cells are actually called "killer cells.") T cells also are involved in
helping signal other cells (like phagocytes) to do their jobs.

Antibodies also can neutralize toxins (poisonous or damaging substances) produced

by different organisms. Lastly, antibodies can activate a group of proteins called complement
that are also part of the immune system. Complement assists in killing bacteria, viruses, or
infected cells.

All of these specialized cells and parts of the immune system offer the body protection
against disease. This protection is called immunity.

16 | P a g e
 b. Bone Marrow

Bone marrow is a semi-solid tissue which may be found within the spongy or
cancellous portions of bones. It is composed of hematopoietic cells, marrow adipose tissue,
and supportive stromal cells. In adult humans, bone marrow is primarily located in the ribs,
vertebrae, sternum, and bones of the pelvis. On average, bone marrow constitutes 4% of the
total body mass of humans; in an adult having 65 kilograms of mass (143 lb), bone marrow
typically accounts for approximately 2.6 kilograms (5.7 lb). Human marrow produces
approximately 500 billion blood cells per day, which join the systemic circulation via
permeable vasculature sinusoids within the medullary cavity. All types of hematopoietic cells,
including both myeloid and lymphoid lineages, are created in bone marrow; however,
lymphoid cells must migrate to other lymphoid organs (e.g. thymus) in order to complete
maturation.

17 | P a g e
 b.1. Bone Marrow Structure

The composition of marrow is dynamic, as the mixture of cellular and non-cellular

components (connective tissue) shifts with age and in response to systemic factors. In
humans, marrow is colloquially characterized as "red" or "yellow" marrow (Latin: medulla
ossium rubra, Latin: medulla ossium flava, respectively) depending on the prevalence of
hematopoetic cells vs fat cells. While the precise mechanisms underlying marrow regulation
are not understood, compositional changes occur according to stereotypical patterns. For
example, a newborn baby's bones exclusively contain hematopoietically active "red" marrow,
and there is a progressive conversion towards "yellow" marrow with age. In adults, red
marrow is found mainly in the central skeleton, such as the pelvis, sternum, cranium, ribs,
vertebrae and scapulae, and variably found in the proximal epiphyseal ends of long bones
such as the femur and humerus. In circumstances of chronic hypoxia, the body can convert
yellow marrow back to red marrow to increase blood cell production.

c. Hematopoietic Components

At the cellular level, the main functional component of bone marrow includes the
progenitor cells which are destined to mature into blood and lymphoid cells. Marrow contains
hematopoietic stem cells which give rise to the three classes of blood cells that are found in
circulation: white blood cells (leukocytes), red blood cells (erythrocytes), and platelets
(thrombocytes).

Cellular constitution of the red bone marrow parenchyma

Average Reference
Group Cell type
fraction range
Myeloblasts 0.9% 0.2–1.5
Promyelocytes 3.3% 2.1–4.1
Myelopoietic
Neutrophilic myelocytes 12.7% 8.2–15.7
cells
Eosinophilic myelocytes 0.8% 0.2–1.3

18 | P a g e
 Neutrophilic
15.9% 9.6–24.6
metamyelocytes
Eosinophilic
1.2% 0.4–2.2
metamyelocytes
Neutrophilic band cells 12.4% 9.5–15.3
Eosinophilic band cells 0.9% 0.2–2.4
Segmented neutrophils 7.4% 6.0–12.0
Segmented eosinophils 0.5% 0.0–1.3
Segmented basophils and
0.1% 0.0–0.2
mast cells

Pronormoblasts 0.6% 0.2–1.3

Erythropoietic Basophilic normoblasts 1.4% 0.5–2.4
cells Polychromatic normoblasts 21.6% 17.9–29.2
Orthochromatic normoblast 2.0% 0.4–4.6
Megakaryocytes < 0.1% 0.0-0.4
Plasma cells 1.3% 0.4-3.9
Other cell
Reticular cells 0.3% 0.0-0.9
types
Lymphocytes 16.2% 11.1-23.2
Monocytes 0.3% 0.0-0.8

The stroma of the bone marrow includes all tissue not directly involved in the
marrow's primary function of hematopoiesis. Stromal cells may be indirectly involved in
hematopoiesis, providing a microenvironment that influences the function and
differentiation of hematopoeietic cells. For instance, they generate colony stimulating
factors, which have a significant effect on hematopoiesis. Cell types that constitute the bone
marrow stroma include:

• fibroblasts (reticular connective tissue)

• macrophages, which contribute especially to red blood cell production, as they deliver
iron for hemoglobin production.
• adipocytes (fat cells)
• osteoblasts (synthesize bone)
• osteoclasts (resorb bone)
• endothelial cells, which form the sinusoids. These derive from endothelial stem cells,
which are also present in the bone marrow.

Normally, the bone marrow makes blood stem cells (immature cells) that become
mature blood cells over time. A blood stem cell may become a myeloid stem cell or a lymphoid

19 | P a g e
stem cell. A lymphoid stem cell becomes a white blood cell. A myeloid stem cell becomes one
of three types of mature blood cells:

• Red blood cells that carry oxygen and other substances to all tissues of the body.
• White blood cells that fight infection and disease.

E. Pathophysiology
Cancer is a process of uncontrolled abnormal cell growth and development. Under
normal circumstances, cells are formed, mature, carry out their intended function and then
die. New cells are constantly regenerated in the body to replace those cells and to maintain
normal cellular function. Cancer represents the disturbance of this process, which can occur
in several ways. Cells may grow and reproduce in a disorganized and out of control fashion.
Cells may fail to develop properly, so they will not function normally. Cells may fail to die
normally. One or a combination of these processes may occur when cells become cancerous.

Leukemia is a cancer of blood forming cells in the bone marrow. These deranged
immature cells accumulate in the blood and within organs of the body. They are not able to
carry out the normal functions of blood cells. Normal blood contains 3 major groups of cells:
white blood cells, red blood cells and platelets. All 3 types of blood cells develop from one
immature cell type, called blood/marrow stem cells, in a process called hematopoiesis. These
stem cells divide and develop to a more developed, but still immature precursor, called a
blast, which then develops through several more stages, into a mature blood cell. This process
takes place in the bone marrow which is the soft spongy material found in the center of most
bones.

20 | P a g e
 The first step in the process of stem cell maturation is differentiation into 2 groups:

• The myeloid stem cells – or lineage, develop into red blood cells, platelets and
certain types of white blood cells (granulocytes or monocytes)
• The lymphoid stem cells – or lineage, develop into another type of white blood cell
(lymphocytes)

Either lineage can be affected by leukemia. Leukemias that affect the myeloid lineage
are called myelocytic also myelogenous, myeloblastic or nonlymphocytic leukemias.

Each of the 2 major types of leukemia, myelogenous and lymphocytic, include both
acute and chronic forms.

• Acute essentially refers to a disorder of rapid onset. In the acute myelocytic

leukemias, the abnormal cells grow rapidly and do not mature. Most of these
immature cells tend to die rapidly. In the acute lymphocytic leukemias, growth is
not as rapid as that of the myelocytic cells. Rather, the cells tend to accumulate.
Common to both types of leukemia is their inability to carry out the functions of
healthy white blood cells. Untreated, death occurs within weeks of a few months.

21 | P a g e
 • In the chronic leukemias, the onset tends to be slow and the cells generally
mature abnormally and often accumulate in various organs, often over long
intervals. Their ability to fight infections and assist in repairing injured tissues is
impaired. However, unlike the acute forms of leukemia, untreated, these
disorders may persist for many months or as in the chronic lymphocytic group,
many years. A distinctive feature of the chronic myelocytic type is its invariable
conversion. If untreated, to a more rapidly fulminating acute type, leading to rapid
death.

Acute myeloid leukemia is caused by a series of acquired genetic aberrations.

Malignant transformation usually occurs at the pluripotent stem cell level, although it
sometimes involves a committed stem cell with more limited capacity for self-renewal.
Abnormal proliferation, clonal expansion, aberrant differentiation, and diminished apoptosis
(programmed cell death) lead to replacement of normal blood elements with malignant cells.

In AML, the myeloid stem cells usually become a type of immature white blood cell
called myeloblasts (or myeloid blasts). The myeloblasts in AML are abnormal and do not
become healthy white blood cells. Sometimes in AML, too many stem cells become abnormal
red blood cells or platelets. These abnormal white blood cells, red blood cells, or platelets are
also called leukemia cells or blasts. Leukemia cells can build up in the bone marrow and blood
so there is less room for healthy white blood cells, red blood cells, and platelets. When this
happens, infection, anemia, or easy bleeding may occur. The leukemia cells can spread
outside the blood to other parts of the body, including the central nervous system (brain and
spinal cord), skin, and gums.

When a large number of blasts or leukemic cells appear in the bone marrow, several
things happen. As the leukemic blast cells accumulate in the bone marrow, they begin to
crowd out the normal blood cells that develop there. Eventually, they take up so much room
that red blood cells, platelets, and normal white blood cells cannot be produced. When that
happens, the young person develops symptoms indicating that normal blood cells are not
being manufactured in adequate numbers. If red blood cells are crowded out by leukemic
cells, the blood will look thin, which makes the patient look pale. The young person also may
be tired because the thin blood cannot carry enough oxygen to the heart, lungs and muscles.
If blood platelets are crowded out in the bone marrow, the young person may have bleeding
problems and unusual bruising. If the normal, mature kind of white cells known as neutrophils
is crowded out by the blasts, there will be no cells to combat bacteria and infections may
occur.

In some cases, leukemic blasts may spill over from the bone marrow into the blood,
where they can be seen by microscopic examination. This may cause a rise in the number of
white cells in the blood. In other cases, only a few blasts appear in the blood and the white
cell count does not change much. When leukemic blasts are present in the blood, they may

22 | P a g e
be carried to other places in the body and enter various body organs. Sometimes they grow
in these organs as well as in the bone marrow.

A picture of normal blood cells. A picture of Acute Myeloid Leukemia blood.

a. Classification

Acute myeloid leukemia has a number of subtypes and precursor neoplasms that are
distinguished from each other by morphology, immunophenotype, cytochemistry, and
genetic abnormalities, all of which have important implications for prognosis and treatment.
Seven classes are described in the WHO classification, including

• AML with recurrent genetic abnormalities

• AML with myelodysplasia-related features

23 | P a g e
• Therapy-related AML (t-AML)
• AML, not otherwise specified (NOS)
• Myeloid sarcoma
• Myeloid proliferations related to Down syndrome
• Blastic plasmacytoid dendritic cell neoplasm

24 | P a g e
 Morphologic criteria from the previous French-American-British (FAB) classification
system are used for subtypes that are not otherwise specified (NOS).

• Acute promyelocytic leukemia (APL) is a subtype of AML with recurrent genetic

abnormalities. APL is a particularly important subtype, representing 10 to 15% of all
cases of AML, striking a younger age group (median age 31 yr) and particular ethnicity
(Hispanics). Patients commonly present with a coagulation disorder (eg, disseminated
intravascular coagulation [DIC]).
• Therapy-related AML (t-AML) is a subtype of AML caused by prior treatment with
certain antineoplastic drugs (eg, alkylating agents and topoisomerase II inhibitors).
Most t-AMLs occur 3 to 10 yr after initial therapy, with a longer latency for alkylating
agents (mean latency 5 to 7 yr) than for topoisomerase II inhibitors (mean latency 6
mo to 3 yr). Alkylating agents cause chromosomal deletions and unbalanced
translocations. Topoisomerase II inhibitors lead to balanced chromosomal
translocations.
• Myeloid sarcoma is characterized by extramedullary myeloblastic infiltration of skin
(leukemia cutis), gingiva, and other mucosal surfaces.

b. CAUSES

The cause of acute myelogenous is damage to the DNA of developing cells in

your bone marrow. Under normal circumstances, your DNA is like a set of instructions for
your cells telling them how and when to grow and divide. Certain genes on your DNA called
oncogenes promote cell division and cause cells to die at the appropriate times.

Acute myelogenous leukemia can occur when damage to DNA turns on

oncogenes or turns off tumor suppressor genes. When this happens, blood cell production
goes awry. The bone marrow produces immature cells that develop into leukemic white blood
called myeloblasts. These abnormal cells are unable to function properly and they can build
up and crowd out healthy cells. The DNA mutations that cause leukemia are usually acquired
rather than inherited but researchers and doctors don’t always understand exactly how. In
some cases, damages to the DNA is the result of exposure to cancer causing chemicals,
including previous chemotherapy for other cancers. There’s also a chance of AML progressing
from other blood diseases and chronic leukemias such as chronic myelogenous leukemia,
myelodysplasia or other disorders in which the bone marrow produces too much of certain
types of blood cells (myeloproliferative disorders).

c. RISK FACTORS

The risk of acute myelogenous leukemia increases with age. It’s most prevalent
in people in their 60s and older. The disorder is also more common in males than females.
Other possible risk factors include the following:

25 | P a g e
 • Exposure to radiation and certain chemicals- people exposed to very high levels of
radiation such as survivors of an atomic blast or a nuclear reactor accident have an
increased risk of developing AML. Exposure to certain chemicals such as benzene
which is found in unleaded gasoline and used by chemical industry also linked to
greater risk of AML.
• Smoking- AML is linked to cigarette smoke which contains benzene and other known
cancer-causing chemicals. Smokers older than 60 face twice the risk of AML than
nonsmokers do.
• Cancer therapy- people who’ve had certain types of chemotherapy and radiation
therapy or treatment for childhood acute lymphocytic leukemia (ALL) may have
greater risk of developing AML.
• Genetic disorder- Certain genetic disorders such as Down syndrome are associated
with an increased risk of AML.
• Other blood disorders- people who’ve had other blood disorder such as
myelodysplasia, polycythemia vera or thrombocythemia are at greater risk of
developing AML.

d. PATIENT’S SIGNS AND SYMPTOMS

Classical Symptoms Clinical Symptoms Rationale

Anemia Manifested Signs and symptoms
of anemia are
• Dyspnea or difficulty of breathing Upon assessment, evident due to the
• Shortness of breath during activity patient generally low amount of
• Dizziness/lightheadedness looks pale in hemoglobin caused
• Extreme Fatigue appearance by lack of properly
• Pale looking skin specifically her functioning cells due
• Cold hands and feet conjunctiva, palm of to overcrowding by
• Tachycardia her hands and nail leukemia cells. There
beds. Patient is a decrease in
describes feeling oxygen capacity of
weak, shortness of hemoglobin causing
breath during decrease in oxygen in
activity and the body or tissue
dizziness. hypoxia. Hypoxia
may result to
Laboratory Findings: shortness of breath,
lightheadedness,
Hemoglobin level: 72
extreme fatigue and
g/L
weakness.

26 | P a g e
Thrombocytopenia Manifested In AML, there is loss
of bone marrow
• Superficial bleeding into the skin During inspection, function because of
that appears as a rash of pinpoint- the patient has the replacement of
sized reddish-purple spots visible pinpoint the malignant cells
(petechiae), usually on the lower petechiae seen on thus decreasing the
legs. her upper and lower production of
• Blood in stool extremities, platelets. Bleeding is
• Jaundice predominantly in the evident due to
lower extremities. decrease circulating
Patient’s sclera is platelet or impaired
noticeably slightly platelet function.
yellowish. Prior to Bleeding which
admission, patient results from platelet
reported black tarry deficiency commonly
stool. occurs in small
vessels and is
Laboratory Findings: characterized by
petechiae.
Platelet count: 40
x10^9/L
Total Bilirubin: 34.2
umol/L
Direct Bilirubin:26.3
umol/L

Neutropenia Manifested The bone marrow

produces immature
• Fever Patient reported cells that usually
• Infection: swollen lymph nodes, having fever 3 days develop into a type
swollen tonsils prior to admission of abnormal white
ranging from 37.8 to blood cell in AML.
38.9 degrees Celcius. These abnormal cells
Upon inspection, are unable to mature
tonsillar and and perform their
superficial cervical usual functions. They
lymph nodes are also multiply rapidly
swollen. Pain and can crowd out
reported during healthy cells, leaving
palpation. Tonsils are a person with acute
both inflamed, rated myelogenous
at grade 3+. Patient

27 | P a g e
 reported difficulty of leukemia vulnerable
swallowing. to infection.

Laboratory Findings:

Neutrophiles level:
1%
(1 week prior to
admission)

Oral Thrush/oral candidiasis Manifested Immunosupressed

patient commonly
• White milk like patches in the During assessment, has infection in oral
tongue white milk like mucous membrane.
• Metallic/unpleasant taste in the patches seen in the Acute leukemia is
mouth tongue. Patient was often accompanied
• Redness inside the mouth and instructed to remove by oral symptoms,
throat dentures to examine which are reported
• White and red patches seen in the palate, red and to be early
upper palate white spots seen. manifestations of
• Pain and burning sensation in the Patient reported acute leukemia in
mouth metallic like taste some patients.
and loss of appetite.
Pain is also reported
upon swallowing.

28 | P a g e
 e. DIAGNOSIS

The following tests and procedures may be used:

• Physical exam and history: An exam of the body to check general signs of health,
including checking for signs of disease, such as lumps or anything else that seems
unusual. A history of the patient’s health habits and past illnesses and treatments will
also be taken.
• Complete blood count (CBC): A procedure in which a sample of blood is drawn and
checked for the following:

• The number of red blood cells, white blood cells, and platelets.
• The amount of hemoglobin (the protein that carries oxygen) in the red blood
cells.
• The portion of the sample made up of red blood cells.

Complete blood count (CBC). Blood is collected by inserting a needle into a vein and
allowing the blood to flow into a tube. The blood sample is sent to the laboratory and the red
blood cells, white blood cells, and platelets are counted. The CBC is used to test for, diagnose,
and monitor many different conditions.

• Peripheral blood smear: A procedure in which a sample of blood is checked for blast
cells, the number and kinds of white blood cells, the number of platelets, and changes
in the shape of blood cells.

29 | P a g e
 • Bone marrow aspiration and biopsy: The removal of bone marrow, blood, and a small
piece of bone by inserting a hollow needle into the hipbone or breastbone. A
pathologist views the bone marrow, blood, and bone under a microscope to look for
signs of cancer.

Bone marrow aspiration and biopsy. After a small area of skin is numbed, a bone
marrow needle is inserted into the patient’s hip bone. Samples of blood, bone, and bone
marrow are removed for examination under a microscope.

• Cytogenetic analysis: A laboratory test in which the chromosomes of cells in a sample

of blood or bone marrow are counted and checked for any changes, such as broken,
missing, rearranged, or extra chromosomes. Changes in certain chromosomes may be
a sign of cancer. Cytogenetic analysis is used to help diagnose cancer, plan treatment,
or find out how well treatment is working. Other tests, such as fluorescence in situ
hybridization (FISH), may also be done to look for certain changes in the
chromosomes.
• Immunophenotyping: A laboratory test that uses antibodies to identify cancer cells
based on the types of antigens or markers on the surface of the cells. This test is used
to help diagnose specific types of leukemia. For example, a cytochemistry study may
test the cells in a sample of tissue using chemicals (dyes) to look for certain changes

30 | P a g e
 in the sample. A chemical may cause a color change in one type of leukemia cell but
not in another type of leukemia cell.
• Reverse transcription–polymerase chain reaction test (RT–PCR): A laboratory test in
which the amount of a genetic substance called mRNA made by a specific gene is
measured. An enzyme called reverse transcriptase is used to convert a specific piece
of RNA into a matching piece of DNA, which can be amplified (made in large numbers)
by another enzyme called DNA polymerase. The amplified DNA copies help tell
whether a specific mRNA is being made by a gene. RT-PCR can be used to check the
activation of certain genes that may indicate the presence of cancer cells. This test
may be used to look for certain changes in a gene or chromosome, which may help
diagnose cancer. This test is used to diagnose certain types of AML including acute
promyelocytic leukemia (APL).

f. PROGNOSIS

The prognosis (chance of recovery) and treatment options depend on:

• The age of the patient.

• The subtype of AML.
• Whether the patient received chemotherapy in the past to treat a different cancer.
• Whether there is a history of a blood disorder such as myelodysplastic syndrome.
• Whether the cancer has spread to the central nervous system.
• Whether the cancer has been treated before or recurred (come back).

g. TREATMENT

Different types of treatment are available for patients with adult acute myeloid
leukemia (AML). Some treatments are standard (the currently used treatment), and some are
being tested in clinical trials. A treatment clinical trial is a research study meant to help
improve current treatments or obtain information on new treatments for patients with
cancer. When clinical trials show that a new treatment is better than the standard treatment,
the new treatment may become the standard treatment. Patients may want to think about
taking part in a clinical trial. Some clinical trials are open only to patients who have not started
treatment. The treatment of adult AML usually has 2 phases.

The 2 treatment phases of adult AML are:

• Remission induction therapy: This is the first phase of treatment. The goal is to kill
the leukemia cells in the blood and bone marrow. This puts the leukemia into
remission.

31 | P a g e
 • Post-remission therapy: This is the second phase of treatment. It begins after the
leukemia is in remission. The goal of post-remission therapy is to kill any remaining
leukemia cells that may not be active but could begin to regrow and cause a relapse.
This phase is also called remission continuation therapy.

g.1. Four types of standard treatment are used:

• Chemotherapy - Chemotherapy is a cancer treatment that uses drugs to stop the

growth of cancer cells, either by killing the cells or by stopping them from dividing.
When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs
enter the bloodstream and can reach cancer cells throughout the body (systemic
chemotherapy). When chemotherapy is placed directly into the cerebrospinal fluid
(intrathecal chemotherapy), an organ, or a body cavity such as the abdomen, the drugs
mainly affect cancer cells in those areas (regional chemotherapy). Intrathecal
chemotherapy may be used to treat adult AML that has spread to the brain and spinal
cord. Combination chemotherapy is treatment using more than one anticancer drug.
The way the chemotherapy is given depends on the subtype of AML being treated and
whether leukemia cells have spread to the brain and spinal cord.

32 | P a g e
 Intrathecal chemotherapy. Anticancer drugs are injected into the intrathecal space, which
is the space that holds the cerebrospinal fluid (CSF, shown in blue). There are two different
ways to do this. One way, shown in the top part of the figure, is to inject the drugs into an
Ommaya reservoir (a dome-shaped container that is placed under the scalp during surgery; it
holds the drugs as they flow through a small tube into the brain). The other way, shown in
the bottom part of the figure, is to inject the drugs directly into the CSF in the lower part of
the spinal column, after a small area on the lower back is numbed.

• Radiation therapy- Radiation therapy is a cancer treatment that uses high-energy x-

rays or other types of radiation to kill cancer cells or keep them from growing. There
are two types of radiation therapy:

✓ External radiation therapy uses a machine outside the body to send radiation
toward the cancer.
✓ Internal radiation therapy uses a radioactive substance sealed in needles, seeds,
wires, or catheters that are placed directly into or near the cancer.

The way the radiation therapy is given depends on the type of cancer being treated
and whether leukemia cells have spread to the brain and spinal cord. External radiation
therapy is used to treat adult AML.

• Chemotherapy with stem cell transplant - Chemotherapy is given to kill cancer cells.
Healthy cells, including blood-forming cells, are also destroyed by the cancer
treatment. Stem cell transplant is a treatment to replace the blood-forming cells. Stem
cells (immature blood cells) are removed from the blood or bone marrow of the
patient or a donor and are frozen and stored. After the patient completes
chemotherapy, the stored stem cells are thawed and given back to the patient through
an infusion. These reinfused stem cells grow into (and restore) the body's blood cells.

33 | P a g e
 Stem cell transplant. (Step 1): Blood is taken from a vein in the arm of the donor. The
patient or another person may be the donor. The blood flows through a machine that
removes the stem cells. Then the blood is returned to the donor through a vein in the other
arm. (Step 2): The patient receives chemotherapy to kill blood-forming cells. The patient may
receive radiation therapy (not shown). (Step 3): The patient receives stem cells through a
catheter placed into a blood vessel in the chest.

h. Untreated Adult Acute Myeloid Leukemia

Standard treatment of untreated adult acute myeloid leukemia (AML) during the remission
induction phase depends on the subtype of AML and may include the following:

• Combination chemotherapy.
• High-dose combination chemotherapy.
• Low-dose chemotherapy.
• Intrathecal chemotherapy.
• All-trans retinoic acid (ATRA) plus arsenic trioxide for the treatment of acute
promyelocytic leukemia (APL).
• ATRA plus combination chemotherapy followed by arsenic trioxide for the treatment
of APL.

i. Adult Acute Myeloid Leukemia in Remission

Treatment of adult AML during the remission phase depends on the subtype of AML and
may include the following:

• Combination chemotherapy.

34 | P a g e
• High-dose chemotherapy, with or without radiation therapy, and stem cell
transplant using the patient's stem cells.
• High-dose chemotherapy and stem cell transplant using donor stem cells.
• A clinical trial of arsenic trioxide.

35 | P a g e
F. Diagnostic/Laboratory Exams

Complete Blood Count Prior to Admission

36 | P a g e
37 | P a g e
38 | P a g e
COMPLETE BLOOD COUNT DURING ADMISSION

39 | P a g e
40 | P a g e
41 | P a g e
42 | P a g e
LIVER & KIDNEY PROFILE

43 | P a g e
HEPATITIS SCREENING

44 | P a g e
FASTING BLOOD SUGAR

45 | P a g e
KIDNEY PROFILE

46 | P a g e
URINALYSIS

47 | P a g e
BLOOD CULTURE & SENSITIVITY

48 | P a g e
URINE CULTURE & SENSITIVITY

49 | P a g e
ELECTROCARDIOGRAM

50 | P a g e
 G. NURSING CARE PLAN

Assessment Nursing Diagnosis Desired Outcomes Interventions Rationale Evaluation

Subjective: Activity Report a measurable Evaluate reports of Effects of leukemia, anemia, Goal met.
Patient verbalizes “Ang Intolerance increase in activity fatigue, noting and chemotherapy may be
bilis ko mapagod kahit related to tolerance. inability to cumulative (especially Patient demonstrated
hindi ako masyadong imbalance participate in during acute and active decrease in physiological
kumikilos. Lagi din ako between oxygen activities or ADLs. treatment phase), intolerance as
hinihingal.” supply and necessitating assistance. manifested by normal
demand heart rate of 81 beats per
Objective: minute.
• Exertional
discomfort or Participate in ADLs to Encourage patient to Helps patient prioritize
dyspnea level of ability. keep a diary of daily activities and arrange them
• Tachycardia Demonstrate a routines and energy around fatigue pattern.
HR = 105bpm decrease in levels, noting
• Spo2 = 91 – physiological signs of activities that
93% with intolerance; e.g., increase fatigue.
supplemental pulse, respiration,
oxygen via and BP remain within
nasal cannula patient’s normal
at 2lpm range.

51 | P a g e
Provide quiet Restores energy needed for
environment and activity and cellular
uninterrupted rest regeneration and/or tissue
periods. Encourage healing.
rest periods before
meals.

Implement energy- Maximizes available energy

saving techniques for self-care tasks.
(sitting, rather than
standing, use of
shower chair). Assist
with ambulation and
other activities as
indicated.

Schedule meals. May enhance intake by

Give oral hygiene reducing nausea.
before meals and
administer
antimetics as
indicated.

52 | P a g e
 Recommend small, Smaller meals require less
nutritious, high- energy for digestion than
protein meals and larger meals. Increased
snacks throughout intake provides fuel for
the day. energy.

Maintain Maximizes oxygen available

supplemental for cellular uptake,
oxygen improving tolerance of
activity.
Subjective: Risk for Deficient Demonstrate Monitor I&O. Tumor lysis syndrome Goal met.
Patient verbalizes Fluid Volume adequate fluid Calculate insensible occurs when destroyed
“Masakit pa din ang related to volume, as evidenced losses and fluid cancer cells release toxic Patient exhibited
lalamunan ko, decrease fluid by stable vital signs; balance. Note levels of potassium, adequate fluid volume as
nahihirapan ako lumunok intake due to palpable pulses; urine decreased urine phosphorus, and uric acid. evidenced by stable vital
kahit tubig” vomiting, difficulty output, specific output in presence Elevated phosphorus and signs HR = 75 bpm
swallowing and gravity, and pH within of adequate intake. uric acid levels can cause BP = 110/80 mmhg
Objective: throat pain. normal limits. Measure specific crystal formation in the RR = 25
gravity and urine pH. renal tubules, impairing Spo2 = 95%
(+) Vomiting filtration and leading to
(+) Dizziness renal failure.

53 | P a g e
(+) Oral thrush seen on Identify individual risk Weigh daily. Measure of adequacy of
tongue and palate factors and fluid replacement and
(+) Swollen tonsils appropriate kidney function. Continued
interventions. intake greater than output
may indicate renal insult or
obstruction.

Initiate Promote good Explain that leukemia may

behaviors/lifestyle nutrition. cause weight loss and
changes to prevent anorexia so encourage the
development of patient to eat and drink
dehydration. high-calorie, and high-
protein foods. Note:
Chemotherapy and
adjunctive prednisone may
cause weight gain, so
dietary counseling and
teachings are helpful.

Monitor BP and HR. Changes may reflect effects

of hypovolemia (bleeding or
dehydration).

54 | P a g e
Evaluate skin turgor, Indirect indicators of fluid
capillary refill, and status or hydration.
general condition of
mucous
membranes.

Note presence of Affects intake, fluid needs,

nausea, fever and route of replacement.

Inspect skin or Suppression of bone

mucous membranes marrow and platelet
for petechiae, production places patient at
ecchymotic areas; risk for spontaneous or
note bleeding gums, uncontrolled bleeding.
frank or occult blood
in stools and urine;
oozing from
invasive-line sites.
Implement
measures to prevent
tissue injury or
bleeding, gentle
brushing of teeth or

55 | P a g e
gums with soft
toothbrush, cotton
swab, or sponge-
tipped applicator;
using electric razor
and avoiding sharp
razors when shaving;
avoiding forceful
nose blowing and
needlesticks when
possible; using
sustained pressure
(sandbags or
pressure dressings)
on oozing puncture
and IV sites.

Provide adequate Fragile tissues and altered

hydration, and a clotting mechanisms
high-residue diet, increase the risk of
stool softners, and hemorrhage following even
mild laxatives. minor trauma.

56 | P a g e
Limit oral care to To prevent constipation.
mouthwash if
indicated. Avoid
mouthwashes with
alcohol.

Provide soft diet. When bleeding is present,

even gentle brushing may
cause more tissue damage.
Alcohol has a drying effect
and may be painful to
irritated tissues.

Administer IV fluids May help reduce gum

as indicated. irritation.

57 | P a g e
 Administer Maintains fluid and
medication as electrolyte balance in the
indicated and absence of oral intake;
ordered by the prevents or minimizes
physician: tumor lysis syndrome,
reduces risk of renal
complications.

Antiemetics: 5-HT3 Relieves nausea and/or

receptor antagonist vomiting.
drugs such as
ondansetron
(Zofran) or
granisetron (Kytril)

Patient is Risk for infection Identify actions to Place in a private To protect the patient from Goal partially met.
immunosuppressed with related to prevent/reduce risk room. Limit visitors potential sources of
Neutrophiles of 1% prior inadequate of infection. as indicated. Prohibit pathogens or infection. Patient has no fever but
to admission. secondary live plants or Bone marrow suppression still with swollen lymph
defenses flowers. Restrict and neutropenia place the nodes and tonsils. Blood
fresh fruits and make patient at high risk for culture and urine culture
sure they are infection. initial result of now
properly washed or growth.
peeled. Coordinate
patient care so that

58 | P a g e
 leukemic patient
doesn’t come in
contact with staff
that also cares for
patients with
infections or
infectious diseases.

Demonstrate Require good hand Prevents cross-

techniques, lifestyle washing protocol for contamination and reduces
changes to promote all personnel and risk of infection.
safe environment, visitors.
achieve timely
healing.

Closely monitor Although fever may

temperature. Note accompany some forms of
correlation between chemotherapy, progressive
temperature hyperthermia occurs in
elevations and some types of infections,
chemotherapy and fever (unrelated to
treatments. Observe drugs or blood products)
for fever associated occurs in most leukemia
with tachycardia, patients. Septicemia may
hypotension, and occur without fever.

59 | P a g e
subtle mental
changes.

Prevent chilling. Helps reduce fever, which

Force fluids, contributes to fluid
administer tepid imbalance, discomfort, and
sponge bath. CNS complications.

Encourage frequent Prevents stasis of

turning and deep respiratory secretions,
breathing. reducing risk of atelectasis
or pneumonia.

Auscultate breath Early intervention is

sounds, noting essential to prevent sepsis
crackles, rhonchi. in immuno-suppressed
Inspect secretions person.
for changes in

60 | P a g e
characteristics:
increased sputum
production or
change in sputum
color. Observe urine
for signs of infection:
cloudy, foul-
smelling, or
presence of urgency
or burning with
voids.

Handle patient Prevents sheet burn and

gently. Keep linens skin excoriation.
dry and wrinkle-free.

Inspect skin for May indicate local infection.

tender, Open wounds may not
erythematous areas; produce pus because of
open wounds. insufficient number of
Cleanse skin with granulocytes.
antibacterial
solutions.

61 | P a g e
Inspect oral mucous The oral cavity is an
membranes. Provide excellent medium for
good oral hygiene. growth of organisms and is
Use a soft susceptible to ulceration
toothbrush, sponge, and bleeding.
or swabs for
frequent mouth
care.

Avoid using These can provide an

indwelling urinary avenue for infection.
catheters and giving
I.M. injections.

Provide thorough Additional measures to

skin care by keeping avoid infection.
the patient’s skin
and perianal area
clean; apply mild
lotion or creams to
keep the skin from
drying or cracking.
Thoroughly clean
skin before all

62 | P a g e
invasive skin
procedures.

Change IV tubing IV sites can harbor infection.

according to your Additional measure to avoid
facility’s policy. Use infection.
strict sterile
technique and a
metal scalp vein
needles (metal
butterfly needle)
when starting IV. If
the patient receives
total parenteral
nutrition, give
scrupulous
subclavian catheter
care.

Promote good Promotes cleanliness,

perianal hygiene. reducing risk of perianal
Examine perianal abscess; enhances
area at least daily circulation and healing.
during acute illness. Perianal abscess can
Provide sitz baths, contribute to septicemia
using Betadine or

63 | P a g e
Hibiclens if and death in immune
indicated. Avoid compromised patients.
rectal temperatures,
use of suppositories

64 | P a g e
 H. DRUG STUDY

Date ordered Generic Classificati Dosage Mechanism of Indications Contraindications Side effects/ Nursing
Name on action Adverse effects Responsibilities

September 7, Piperacillin Penicillin 4.45g IV q Piperacillin Moderate to Patients hypersensitive CNS: pain, headache, Administer
2019 sodium and Antibiotic 8 hours inhibits cell severe to the drug or other insomnia, agitation, medication via
tazobactam wall synthesis nosocomial penicillin. fever, dizziness, IV using infusion
sodium during pneumonia anxiety or syringe
microorganis caused by pump.
m pipercaillin
multiplication. resistant.
CV: hypertension,
tachycardia, chest Ask patient
Tazobactam Use cautiously in pain, edema about previous
increases patients with other allergic reaction
piperaacillin drug allergies to penicillin.
effectiveness especially to
by inactivating cephalosporin and in
beta- those with bleeding
lactamase tendencies, uremia or GI: diarrhea, nausea,
which hypokalemia. constipation, Monitor for any
destroys vomiting, dyspepsia, adverse effect.
penicillin. stool changes,
abdominal pain

65 | P a g e
 Hematologic:
thrombocytopenia
Respiratory: dyspnea
September 7, Hydroxyurea Antimetab- 500mg The exact It is used to Hydroxyurea is Signs of an allergic Use
2019 capsule olite BID mechanism by treat leukemia, contraindicated in reaction, like rash; hydroxyurea
which cancer of the patients who have a hives; itching; red, capsules 500 mg
hydroxyurea head and neck hypersensitivity to swollen, blistered, or as ordered by
works to treat hydroxyurea or any peeling skin with or your doctor.
cancer is not other component of its without fever; Read all
understood. formulation. wheezing; tightness information
However, it is in the chest or given to you.
thought that throat; trouble Follow all
hydroxyurea breathing, instructions
causes an swallowing, or closely.
immediate talking; unusual
inhibition of hoarseness; or Take
DNA synthesis swelling of the hydroxyurea
by inhibiting mouth, face, lips, capsules 500 mg
an enzyme tongue, or throat. at the same
called time of day.
ribonucleotide Hair loss.
reductase. Take with or
Interrupting Upset stomach. without food.
DNA synthesis
Loss of appetite.
reduces the Take with a full
glass of water.

66 | P a g e
growth of Diarrhea or
cancer cells. Hydroxyurea may constipation. Wash your
cause severe bone hands before
marrow Headache. and after use.
suppression/myelosup
pression Mouth sores. Keep taking
hydroxyurea
Weight gain.
capsules 500 mg
Change in color or as you have
size of a mole. been told by
your doctor or
A skin lump or other health
growth. care provider,
even if you feel
Change in skin or well.
finger nails.
You will need to
Skin ulcers and dead take special
body tissue care when
(gangrene) has handling
happened with hydroxyurea
hydroxyurea capsules 500
capsules 500 mg. mg. Check with
Call your doctor right the doctor or
away if you have pharmacist to
see how to

67 | P a g e
skin ulcers or any handle
other skin changes. hydroxyurea
capsules 500
Some people have mg.
had lung problems
with hydroxyurea Wear gloves
capsules 500 mg. when touching
Sometimes, this has hydroxyurea
been deadly. Call capsules 500
your doctor right mg.
away if you have
signs of lung Swallow whole.
problems like Do not chew,
shortness of breath open, or crush.
or other trouble
breathing, cough If the capsule is
that is new or worse, opened or
or fever. broken, do not
touch the
contents.
xf the contents
are touched or
they get in the
eyes, wash
hands or eyes
right away.

68 | P a g e
September 7, Fluconazole Antifungal 200mg Fluconazole Fluconazole Fluconazole is headache, Taken by mouth
2019 OD has been can be contraindicated in with or without
demonstrated administered in patients who have dizziness, food.
to show the treatment shown hypersensitivity
fungistatic of the following to fluconazole or to any drowsiness, Monitor for
activity fungal of its excipients. There allergic
against the stomach or
infections: is no information reaction.
majority of abdominal pain,
regarding cross-
strains of the 1) Vaginal yeast hypersensitivity
following upset stomach,
infections between fluconazole
microorganis caused by and other azole diarrhea,
ms, curing Candida antifungal agents.
fungal
Caution should be used heartburn,
infections 2) Systemic in prescribing
such as: Candida Flucoazole to patients loss of appetite, and
infections with hypersensitivity to
Candida
other azoles. Co allergic reactions
albicans, 3) Both
administration of including skin
Candida esophageal and inflammation,
glabrata terfenadine is
oropharyngeal itching, rash, and
(Many strains contraindicated in
candidiasis unusual or
are patients receiving
intermediatel unpleasant taste in
4) Cryptococcal Fluconazole at multiple your mouth.
y doses of 400 mg/day or
meningitis
susceptible), higher based upon
Candida results of a multiple
parapsilosis, dose interaction study.

69 | P a g e
Candida 5) UTI (urinary Coadministration of
tropicalis, tract infection) other drugs known to
Cryptococcus by Candida prolong the QT interval
neoformans and which are
6) Peritonitis metabolized via the
This is (inflammation enzyme CYP3A4 such
achieved of the as cisapride,
through peritoneum) astemizole,
steroidal caused by erythromycin,
inhibition in Candida pimozide, and
fungal cells,
quinidine are
interfering A note on contraindicated in
with cell wall fungal infection patients receiving
synthesis and prophylaxis
growth as fluconazole.
well as cell Patients
adhesion, receiving bone
thereby marrow
treating transplantation
fungal
who are
infections and
treated with
their
cytotoxic
symptoms.
chemotherapy
and/or
radiation
therapy may be
predisposed to

70 | P a g e
candida
infections, and
may receive
fluconazole as
prophylactic
therapy.

71 | P a g e
II. Program Proposal on Cancer Prevention and Control

I. Project Title: Leukemia Awareness and Prevention Program

A. Rationale

Leukemia is among the top 5 killer cancers in the Philippines. It is consider as a silent
killer due to the fact that only a handful of people know what Leukemia and how we can
prevent and detect it. September was the n designated as “Leukemia Awareness Month”
coinciding with the “Blood Cancer Awareness month” and is celebrated internationally also
in September.

Due to the alarming increase in new cases of Leukemia emerging in our country, the
Department of Health exerts their effort in disseminating information on how we can prevent
and detect this disease. With the little information on the disease available, our country’s
major worry is that it will continue to go undiagnosed and untreated if no emergent effort
and attention will be given to it. Organizing an awareness campaign can help spread the
information about Leukemia.

Leukemia is a cancer of the blood which has different subtypes. Acute subtypes are
more aggressive with poor prognosis. If detected and treated early, chances of surviving is
high. This project aims to reach out to Filipinos living in Manila who are unaware of this
disease. This event can also provide help to already diagnosed patients through blood and
medical donations. Treatment for cancers such as Leukemia are expensive and the main goal
of this program is to provide free treatment for patients who belong under the poor sector of
our country specifically those who are already in their senior years.

B. Objectives: Prevention, Early Detection, Early Diagnosis and Early Treatment

a. Specific Objectives
• To create awareness about Leukemia, its effect and how we can
prevent it.
• To identify existing patients suffering from Leukemia
• To provide treatment services to indigent patients and those that
belong in the poor sector of our country.
• To coordinate with Philippine Red Cross in conducting a
bloodletting/donation activity where in blood bags collected will be
donated to Leukemia patients admitted in the Philippine General
Hospital.

72 | P a g e
 C. Content

The program content will focus on the following:

• Prevention
• Early detection/diagnosis
• And early treatment.

Prevention is always better than cure, under this subject; the event will provide a talk
on what Leukemia is and how we can prevent it. Leukemia can be both inherited and acquired.
The dialogue will focus on how Leukemia acquired from chemical and radiation exposure.
Through this, people can be aware on the harmful effects of being exposed to chemicals and
radiation. I will be including recent concrete studies on how a person can get Leukemia just
by using products contaminated with harmful chemicals. Education material in the form of
leaflets and posters shall be provided during the talk.

Early detection and diagnosis will also be a discussion that will be headed by a
hematologist speaker who will focus on the early signs and symptoms of Leukemia and how
we can address it. The speaker will discuss how a basic complete blood count test can early
detect Leukemia. I will be also providing list of clinics and contact numbers of hematologist in
Metro Manila.

Lastly, the subject regarding treatment will be headed by an oncologist/hematologist

who will briefly discuss about the latest treatment for Leukemia. During this part, in
partnership with Philippine Red Cross, a bloodletting drive shall be conducted wherein blood
bags will be donated to the Leukemia patient admitted in the Philippine General Hospital.

D. Methodology

The idea of generating this event came from my mother’s journey battling Leukemia.
Fighting side by side with her made me notice the lack of awareness amongst the public in
general regarding this disease. In order to bring this event to life, a core committee of
volunteers comprising of experts from various medical institutes of repute will be formed and
organized. The committee shall plan the program, recruits additional volunteers, disseminate
invitations in all media platforms and organize the partnership with Philippine Red Cross and
Philippine General Hospital.

E. Operating details

▪ Resource speaker: Hematologist, Oncologist, Cancer Survivors and

Celebrity Advocates

73 | P a g e
 ▪ Participants: Target participants include healthy man and
woman aged 20 above living in Manila. Cancer patients and survivors
will also be invited to attend this event.
▪ Venue: Ortigas Hospital and Healthcare Center Cainta,
Rizal
▪ Date: September 29, 2019 Sunday
▪ Funding source: Donations and Sponsorships
▪ Length of program: 5 hours from 12pm to 5pm

F. Resource requirements

Donations and sponsorships will be the main source of budget of this event. The
committee will be looking for people who will be willing to donate, volunteer and sponsor in
exchange for advertisement and promotion during the pre-launching and event itself. The
budget shall be divided into the following:

• Speakers and talents: 30%

• Marketing and promotion: 30%
• Printed materials and other eqipment: 30%
• Venue: 10%

To help raise the budget, the committee will try to get social media influencers to
promote the event and partnering with brands and local business.

74 | P a g e
G. Appendix

a. Sample invitation

75 | P a g e
b. Sample Program

Leukemia Awareness and Prevention Program

Schedule of Activities
Ortigas Hospital & Healthcare Center
September 29, 2019
12:00 pm

12:00 pm Registration
12:30 pm Start of Bloodletting/Donation in partnership with
Philippine Red cross and Philippine General Hospital
Opening Remarks
1:00 pm What is Leukemia?
Speaker: Dr. Jennifer Alabado (Hematologist)
2:00 pm Leukemia Early Detection and Diagnosis
Speaker: Dr. Ivy Mae Escasa (Hematologist)
3:00 pm Leukemia Treatments
Speaker: Dr. Angelina Mirasol
4:00 pm Story of Leukemia Survivors
4:30 pm Closing Remarks and End of Bloodletting

76 | P a g e
September 25, 2019

Dr. Angelina Mirasol

Internal Medicine – Hematologist
Philippine General Hospital
Taft Avenue, Manila

Dear Dr. Mirasol,

Greetings!

In behalf of Ortigas Hospital & Healthcare Center staff, It is my pleasure to invite you as our
Resource Speaker for our “Leukemia Awareness and Prevention Program” to be held on
Septemebr 29, 2019 Sunday 12:00 in the afternoon at Ortigas Hospital & Healthcare Center
Ortigas Avenue Extension Cainta, Rizal.

The lecture will discuss the importance of early treatment for Leukemia patients including
the possible treatments that are currently available in the Philippines.

By accepting this invitation, you will acquaint all participants that will be joining us including
Cancer patients and survivors who will greatly benefit from this program.

We are hoping for your favorable response. Thank you and more power.

Respectfully Yours,

Wella Joy P. Diola

Neonatal Intensive Care Unit Nurse
Ortigas Hospital & Healthcare Center

77 | P a g e
 LEUKE What are What are
the the signs
MIA categories and
WHAT YOU NEED TO of symptoms
KNOW ABOUT THIS
LEUKEMIA? of
GROUP OF BLOOD
•
CANCERS? ACUTE LEUKEMIA
LEUKEMIA?
- Progress rapidly and
needs immediate
treatment. Person can
feel severely ill.
• CHRONIC LEUKEMIA
- Progress slowly and
treatment may be
delayed. Person can
be asymptomatic/no
symptoms

What is
EARLY
LEUKEMIA? What are
DIAGNOSIS
the types of
SAVES
Leukemia is a type of
LEUKEMIA?
blood cancer that begins LIVES
in the bone marrow. The
bone marrow starts
making abnormal white
blood cells which
overthrow the normal
white blood cells along
with red blood cells and
platelets. All of the
normal cells can no
longer function
correctly.

78 | P a g e
Course evaluation

Course Name:

Instructions: Please complete this course evaluation by assigning each statement a number
corresponds to your opinion. Place an X in the column that corresponds to your answer.

RATING SYSTEM:

1 – Strongly Agree
2 – Agree
3 – Unsure
4 – Disagree
5 – Strongly Disagree

Evaluation 1 2 3 4 5
The speaker is knowledgeable about the subject
The speaker presents material in a way that helps me learn
The content was organize and easy to follow
The speaker answers my question
The materials distributed were helpful
The program objectives were met
The venue and facilities were adequate and comfortable
The program experience will be useful in my life

Do you have any recommendations?

Thank you very much for participating!

79 | P a g e
III. Research Article and Critique

80 | P a g e
A. Article

81 | P a g e
 B. Critique

The article’s problem statement focuses on the non-beneficial intensive

chemotherapy for older patients’ age 70 years old and above who are diagnose with Acute
Myeloid Leukemia. Intensive AML type therapy is consists of 3 + 7 regimen or cytarabine 100-
200mg/m2 daily x 5 – 7 days and daunorubicin 45-90 mg/m2 daily x 3 days. Majority of the
AML trials exclude older patients aged 55-60 years old above due to high incidence of
mortality rate. For the study groups, adults with a diagnosis of AML who were greater than
70 years old treated on frontline cytarabine-based intensive chemotherapy regimens from
1990 until 2008 were evaluated. AML was defined in this analysis by the presence of greater
than 20% myeloblast in the marrow or peripheral blood. Patients with acute promyelocytic
leukemia were excluded from the studies. Induction therapy varied depending on treatment
period and it includes different anthracyclines, topoisomerase I inhibitors, and other
nucleoside analogues. The total number of samples used in this study is 446, 41% are under
Idarubicin + HD ara-C regimen, 22% are on Idarubicin +HD ara-C +fludarabine, 17% are on
Fludarabine + HD ara-C, 11% are on topotecan + HD ara-C + cyclophosphamide, 4% on both
Topotecan + HD ara-C and Miscellaneous + standard or HD ara-C and 2% on Clofarabine + HD
ara-C. (HD = high dose, ara-C = cytarabine). Induction mortality was defined as 8 week
mortality because this was the time when the weekly mortality rate was reduced from the
high initial rates to the lower rates noted during maintenance. Differences among variables
were compared by the X2 tests. Survival was calculated by the Kaplan-Meier method. Survival
among different categories was compared by the log rank test. Variables showing significant
differences were included in the multivariate analysis. Multivariate analyses of prognostic
factors used the logistic regression methods for CR and mortality and the Cox proportional
hazard method survival. AP value <.05 was considered significant in this studies.

In the univariate and multivariate analyses, age was first tested as a continuous
variable. The study identified the 8 week mortality and survival as an important factor making
investigated age in incremental age groups of 5 years for the study to be able to develop user
friendly risk model. Cut off age was set at 80 years old making it as the final multivariate
analysis in the development of the risk model. In the total of 446 patients that was analyzed,
the median age was 74 years old, 13% were greater than 80 years old. Overall response to
intensive chemotherapy: 193 patients achieved CR 45% and 154 or 36% died during remission
induction (8 week mortality). Among the 193 patients achieving CR, 183 95% achieved CR
after 1 course, 9 after 2 courses and 1 after 3 courses. The survival of patients was not
different among patients achieving CR after 1 course or > 1 course, considering the small
numbers of patients in the latter category. The median CR duration was 10.8 months, and the
median survival in patients achieving CR was 13.8 months. The median survival of the total
study group (n = 430) was
91 | P a g e
4.6 months (95% confidence interval, 3.9-6.0). The 1-, 2-, and 3-year survival rates were 28%,
16%, and 10%, respectively (Figure 3). The CR rates were 49% in patients treated before 2000
and 38% in patients treated since 2000.

The primary objective of this analysis was to identify risk events for high mortality rate
with intensive chemotherapy, the study decided to conduct first a multivariate analysis of
prognostic factors associated with 8 week mortality. This identified the following to have
independent adverse significance: older age (80 years), poor performance status, complex
karyotype (greater than 3 abnormalities regardless of the presence or absence of
chromosome 5 or 7 abnormalities), and creatinine level > 1.3 mg/dL. Patients could be
predicted to have 8-week low mortality rate (estimated 8-week mortality < 20%; 28% of
patients; no adverse factors), intermediate mortality rate (estimated 8-week mortality 31%;
40% of patients; 1 adverse factor), and higher mortality rate (estimated 8-week mortality >
50%; 32% of patients; and greater than 2 adverse factors).

The study showed that with the use of intensive chemotherapy in patients greater
than 70 years old with AML showed that, despite the achievement of reasonable CR rates of
40%-50%, the overall survival of these patients remained poor, with a median survival of 4.6
months. The outcome was unchanged over the past 2 decades despite variations in intensive
chemotherapy and improvements in supportive care measures. The 8-week mortality of 36%
in this study group was prohibitively high. . However, 28% of elderly patients, who have none
of these adverse factors, have a reasonable outcome with expected CR rates > 50%, 8-week
mortality rates < 20%, and a median survival of 11.3 months. These patients were
recommended by this study to undergo intensive chemotherapy in leukemia centers with
expertise in intensive supportive care. In such patients, supportive care only or investigational
strategies that do not include cytarabine-based programs may not be justified. However, low-
intensity combination regimens, including low-dose cytarabine, should still be compared with
standard intensive chemotherapy. In summary, the analysis suggested that, although
intensive chemotherapy can be delivered to older patients (age greater than 70 years) with
AML, it may not be beneficial to most, and it could be harmful to some.

From my personal point of view, having a mother who was diagnosed with AML, the
study was reliable and is being applied in current practice by hematologist/oncologist. Acute
myeloid Leukemia is progressive with poor prognosis especially for elder patients. A high dose
7 + 3 chemotherapy regimen is risky for someone of old age. In patients over age 60 diagnosed
with AML, cure rates are under 10% only despite intensive chemotherapy. Just like in my
mother’s case, she was no longer considered a candidate for intensive chemotherapy. Though
she was considered candidate for low dose therapy, the outcome can only help lessen Cancer
cells but never to cure her. The prognosis for older patients will always remain poor despite
recent therapeutic advances. I believe that the most appropriate treatment for each patient
can be chosen on the basis of a risk benefit assessment. This was the kind of approach I dealt
with during the time when I needed to decide on how we will push through with her AML

92 | P a g e
management. This study is beneficial for me and for my practice especially because I
personally experienced it. Finding cure for your loved one will always be a top priority despite
the bitter truth that curing cancers would mean risking their lives during the treatment but
choosing quality of life over quantity is a decision only the patient and his/her loved ones can
make. I decided to choose quality life over quantity not because I lost hope but because of
the extreme sufferings she suffered from this disease. I wanted to give her the chance to live
a normal pain free life over a painful chemotherapy effects that I know will no longer prolong
her life. It was a battle won for us because she ended her suffering and is now in the hands of
God. Due to this disease, I plan on rendering some time in research and volunteer works that
can help spread awareness of what AML truly is. Above all, I wish for a breakthrough in
research and science, to one day find cure for this disease.

93 | P a g e
References:
1. Laudico, A., Mirasol-Lumague, M., Medina, V., Mapua, C., Valenzuela, F., & Pukkala,
E. (2015). 2015 Philippine Cancer Facts and Estimates
2. Katherine, Abel (2013). Official CPC Certification Study Guide. American Medical
Association.
3. Vunjak-Novakovic, G.; Tandon, N.; Godier, A.; Maidhof, R.; Marsano, A.; Martens, T.
P.; Radisic, M. (2010). "Challenges in Cardiac Tissue Engineering". Tissue Engineering
Part B: Reviews. 16 (2): 169–187. doi:10.1089/ten.teb.2009.0352. PMC 2946883.
PMID 19698068.
4. Birbrair, Alexander; Frenette, Paul S. (1 March 2016). "Niche heterogeneity in the
bone marrow". Annals of the New York Academy of Sciences. 1370 (1): 82–96.
doi:10.1111/nyas.13016. ISSN 1749-6632. PMC 4938003. PMID 27015419.
5. Chan, Brian Y.; Gill, Kara G.; Rebsamen, Susan L.; Nguyen, Jie C. (1 October 2016).
"MR Imaging of Pediatric Bone Marrow". RadioGraphics. 36 (6): 1911–1930.
doi:10.1148/rg.2016160056. ISSN 0271-5333. PMID 27726743.
6. Poulton, T B; Murphy, W D; Duerk, J L; Chapek, C C; Feiglin, D H (1 December 1993).
"Bone marrow reconversion in adults who are smokers: MR Imaging findings".
American Journal of Roentgenology. 161 (6): 1217–1221.
doi:10.2214/ajr.161.6.8249729. ISSN 0361-803X. PMID 8249729.
7. Raphael Rubin & David S. Strayer (2007). Rubin's Pathology: Clinicopathologic
Foundations of Medicine. Lippincott Williams & Wilkins. p. 90. ISBN 978-0-7817-
9516-6.
8. Appendix A:IV in Wintrobe's clinical hematology (9th edition). Philadelphia: Lea &
Febiger (1993).
9. Fatahzadeh M, Krakow AM. Manifestation of acute monocytic leukemia in the oral
cavity: a case report. Spec Care Dentist. 2008;28:190–194.
10. Wu J, Fantasia JE, Kaplan R. Oral manifestations of acute myelomonocytic leukemia:
a case report and review of the classification of leukemias. J Periodontol.
2002;73:664–668.
11. PDQ® Adult Treatment Editorial Board. PDQ Adult Acute Myeloid Leukemia
Treatment. Bethesda, MD: National Cancer Institute. Updated <07/23/2019>.
Available at: https://www.cancer.gov/types/leukemia/patient/adult-aml-treatment-
pdq. Accessed <07/23/2019>. [PMID: 26389377]
12. Grossman, S. & Porth, C. (2013). Porth’s Pathophysiology: Concepts of Altered Health
States. 9th Edition
13. Hinkle, J. & Cheever, K. (2017). Brunner & Suddarth’s Textbook of Medical Surgical
Nursing. 14th Edition
14. Vera, M.(2014) Leukemia Nursing Care Plan. Available at http://nurselabs.com

94 | P a g e