Issaiah Nicolle L.

Cecilia 3 BSN - A
Case Study
Case Scenario:
Renee Perez is a 39-year-old woman who noted a nonpruritic nodular rash on her neck and chest
approximately 6 weeks ago. The rash became generalized, spreading to her head, abdomen, and arms and
was accompanied by polyarticular joint pain and back pain. She experienced three episodes of epistaxis in
1 day about 2 weeks ago. Over the past week, her gums have become swollen and tender. Because of the
progression of symptoms and increasing fatigue, she sought medical attention. Lab work was performed,
and Renee Perez was directly admitted to the referred hematology/oncology unit of a teaching hospital
under the care of a hematologist for diagnostic evaluation. Her chest x-ray (CXR) showed normal lung
expansion, heart size normal, and no lymphadenopathy. Skin biopsy showed cutaneous leukemic infiltrates,
and a bone marrow biopsy showed moderately hypercellular marrow and collections of monoblasts. Her
lumbar puncture was free of blast cells. The final diagnosis was acute myeloblastic leukemia. R.P. is to

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begin remission induction therapy with cytarabine (Ara-C) 100 mg/m 2 /day as continuous infusion for 7

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days and idarubicin (Idamycin) 12 mg/m 2 /day IV push for 3 days. She is scheduled in angiography for

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placement of a triple-lumen subclavian Hickman catheter before beginning her therapy.

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■ Chart View
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Laboratory Test Results
CBC
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CBC
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WBC 39,000/mm 3
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Monocytes 64%
Lymphocytes 15%
Neutrophils 4%
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Blasts 17%
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Hgb 10.4 g/dL

Hct 28.7%
Platelets 49,000/mm 3
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1) Interpret R.P.'s CBC results. What does the presence of blasts in the differential mean?
Patient Renee Perez’ complete blood count (CBC) revealed a very elevated white blood cells - 39,000
(normal range is 5000-10,000) and monocytes - 64% (normal range is 2 to 8%). This could mean that there
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is an infection present, and the body is fighting off something. The lymphocytes are slightly decreased -
15% (normal range is 20 to 40%). Having a low level of lymphocytes is called lymphocytopenia could mean
that the body is not producing enough lymphocytes, or the body is destroying them which could lead to
infections. Moreover, neutrophils were also decreased (normal range is 40 to 60%). A low level of
neutrophils is called neutropenia. The patient is at the greatest risk of infection if the neutrophil count drops
below 1,500 neutrophils per microliter. Very low neutrophil counts can lead to life-threatening infections.

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 Meanwhile, the hemoglobin, hematocrit, and platelets were also reduced. A low hemoglobin count can be
associated with a disease or condition that causes your body to have too few red blood cells and a high
hematocrit levels could indicate underlying medical conditions. Lastly, the most important finding is that her
blast cells came back at 17%. Blasts are normally 1 to 5% of marrow cells. In healthy individuals, blasts are
not found in the blood stream and for this patient, it shows that there is excess causing them to dump from
the bone marrow into the blood stream. Having at least 20% blasts is generally required for a diagnosis of
Acute Myeloid Leukemia (AML).
2) What is the purpose of a bone marrow biopsy?
A bone marrow biopsy involves removing a small sample of the bone marrow inside your bones for testing.
Bone marrow is a soft tissue in the center of most large bones. It makes most of the body's blood cells. The
purpose of a bone marrow biopsy is used to diagnosis acute myeloid leukemia and look for chromosomal
and other cell changes.
The pathologist can also check the bone marrow for any of the following:

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 Unexplained anemia (lack of red blood cells)

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Abnormal numbers of blood cells (red blood cells, white blood cells, or platelets)

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
 Lack of iron (iron deficiency)

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 Cancers of the blood-forming tissue (leukemia or lymphoma)
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Cancers that have spread to the bone marrow
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 Response to chemotherapy
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3) Considering all the admission data listed previously, what potential problem will the nurse
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be alert for after the patient returns to the unit following insertion of the catheter?
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Potential problems that can occur are erythema, bleeding, irritation, infection, and displacement. An X-ray is
performed to confirm the placement of the catheter and if it is suspected that the catheter is displaced.
Phlebitis, infiltration, extravasation, and air embolism should also be assessed for.
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4) What assessments are essential for the nurse to make regarding the central catheter
throughout the hospitalization?
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The nurse should monitor for signs of infection (redness, swelling, drainage, tenderness) as well as
monitoring the condition of the dressing and changing it per facility protocol. In addition, watch for a rise in
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HR, BP, RR for issues or complications.

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