Chronic Myeloid Leukemia

PRESENTED BY: JOHN JOSEPH O. DE GUZMAN, R.N JAYBEE BERNANDINO, R.N CATHY T. ROXAS, R.N

Patients Profile:
53 y/o male

Married, with 3 children

Admitted on July 13 2012 Male Medical Service Ward Dx: Chronic Myelogenous Leukemia

History
Pt. has an active lifestyle

Occupation: farmer No history of hypertension or

diabetes Non-smoker Drinks alcohol during some occasions

 does not have history of hospitalization the past year except for clinic visits due to cough and cold
May 2012, the patient observed easy

fatigability and mild dyspnea

when doing activities of daily living he used to do

 July 13 2012, the patient experienced

severe difficulty of breathing. The family decided to seek medical attention and brought him to a secondary level hospital. The hospital then referred the patient to a tertiary level after administering oxygen therapy and stabilizing his vital signs. The doctor then ordered CBC, Xray, ECG and put him on oxygen and complete bed rest without BRP

 (input date)Laboratory findings and further

assessments confirmed that patient has Chronic Myeloid Leukemia and was then prompt for confinement. He was advised to start chemotherapy once he is in better condition to do so. ___ sir nlgay ko n din toh kse un ksunod n sttmnt cnbi ntin n pnstop nia un chemo so i gues ok lng na add toh. un lng nmn =) sorry toxic ha! =p

Due to financial incapability, on August 12, 2012, the patient asked the physician to withdraw all chemotherapeutic treatment except palliative treatments.

Nursing Assessment: Health Perception and Health Management Pattern

Before the patient was diagnosed, the patient

describes his health status as good. He is a non-smoker and an occasional drinker. He never used drugs. He describes his living condition as fair. The past months prior to admission, he experienced frequent cough and cold and seeks medical attention for symptoms cannot be treated by home remedies. The patient manages minor pain symptoms by taking over the counter medications for pain.

Nursing Assessment: Nutrition and Metabolic Pattern

Pt eats 4 times a day. Before admission, his meal

usually has a balanced mix of fruits and vegetables with meat served seldom. Experienced weight loss of around 30kg in the last 6mos Usually takes 6 to 8 glasses of water a day At present, patient describes appetite as fair sometimes experiencing nausea and vomiting

Nursing assessment: Elimination Pattern

The patient was having hematuria and melena

prior to admission Patient defecates twice to thrice per day with no regular schedule (-) retention and no difficulty defecating Sometimes experiencing incontinence

Nursing Assessment: Activity or Exercise Pattern

Generally, because of weakness, the patient

requires assistance in most of the ADLs Patient experiences weakness even after a talking to somebody He is bedridden and requires oxygen to breathe.

Nursing Assessment: Sleep Rest Pattern

The patient sleeps 6 hours at night usually

with periods of naps during daytime and he finds no difficulty sleeping

Nursing Assessment: Cognitive-Perceptual Pattern

Patient is able to read and write

Able to understand physician instructions

regarding medical regimen Drowsy most of the time Sometimes patient experiences epigastric pain but is relieved by pain medications

Nursing Assessment: Self-perception and Self-Concept Pattern

Death is the major concern of the patient and

family If recovered, the patient expects a huge change of lifestyle like wearing mask and strict infection precaution practices

Nursing Assessmen: Role Relationship Pattern

The patient resides with his family in Quezon,

Nueva Ecija The patient has a number of friends in the community that he frequently interact with, but because of the illness, the patient is afraid that he could not interact with them as frequent as before

Nursing Assessment: Sexuality and Reproductive Pattern

The patient before admission assumes the

role of a man thru being a father and husband to his children and wife. He is the provider of the family then. After being aware that he will be bedridden most of the time, he came to acceptance that he cannot provide anymore for the family

Nursing Assessment: Coping- Stress Tolerance Pattern

The patient have experienced many stressful

events in the past and he responds thru confronting the problem With regards to family problems, he often talks to his wife or children before coming up with a solution

Nursing Assessment: Value-Belief Pattern

The patient is a Roman Catholic and believes

that God will never leave him throughout the illness The illness does not interfere with his belief or religious practices. He still finds time to pray and talk to a lay eucharistic minister who sometimes visit him in the hospital

Anatomy and Physiology of the Immune System

Functions:
Protection against invasion of microorganism

from outside the body Protects the body from internal threats and maintains the internal environment by removing dead or damaged cells

 The immune system defends the body

from invading organisms that may cause disease. One part of the immune system uses barriers to protect the body from foreign substances. These barriers include the skin and the mucous membranes, which line all body cavities; and protective chemicals, such as enzymes in saliva and tears that destroy bacteria. Another part of the immune system uses lymphocytes, specialized white blood cells that respond to specific types of foreign invaders.

B LYMPHOCYTES PRODUCE PROTEINS CALLED ANTIBODIES, WHICH CIRCULATE IN THE BLOOD AND ATTACK SPECIFIC DISEASECAUSING ORGANISMS. T LYMPHOCYTES ATTACK INVADING ORGANISMS DIRECTLY.

First lines of defence

saliva antibacterial enzymes
skin prevents entry

tears antibacterial enzymes

mucus linings traps dirt and microbes

good gut bacteria out compete bad

stomach acid low pH kills harmful microbes

Second lines of defence

Involves white blood cells Non-specific response
invading pathogens are targeted by macrophages

Specific response
lymphocytes produce chemicals called antibodies that target specific pathogens

Components
Macrophages

Lymphocytes

Lymphocytes
Lymphocytes are specialized white blood cells whose

function is to identify and destroy invading antigens. All lymphocytes begin as stem cells in the bone marrow Other lymphocytes, called T lymphocytes, or T cells, mature in the thymus, a small glandular organ located behind the breastbone.

 Some T lymphocytes, called cytotoxic

(cell-poisoning) or killer T lymphocytes, generate cell-mediated immune responses, directly destroying cells that have specific antigens on their surface that are recognized by the killer T cells. Helper T lymphocytes, a second kind of T lymphocyte, regulate the immune system by controlling the strength and quality of all immune responses.

 Most contact between antigens and

lymphocytes occurs in the lymphoid organsthe lymph nodes, spleen, and tonsils, as well as specialized areas of the intestine and lungs (see Lymphatic System). Mature lymphocytes constantly travel through the blood to the lymphoid organs and then back to the blood again. This recirculation ensures that the body is continuously monitored for invading substances.

The Bone Marrow

The Bone Marrow

Bone Marrow, soft, pulpy tissue that fills the cavities

of bones, occurring in two forms, red and yellow. One of the largest tissues in the body, bone marrow accounts for 2 to 5 percent of an adults weight. Red marrow, present in all bones at birth, serves as the blood manufacturing center. As an infant matures, most of the red marrow in the shaft of long bones, such as the arm and leg bones, is gradually replaced by yellow marrow. Yellow marrow is composed primarily of specialized fat cells.

The Bone Marrow

While not usually actively involved in

blood formation, in an emergency yellow marrow is replaced by blood-forming red marrow when the body needs more blood

Pathophysiology
Predisposing Factors: Possible Familial Tendency Precipitating Factors: Exposure to Chemical Fertilizers

Myeloblast transformation

Continuous accumulation of immature cells Hypermetabolism Splenomegaly, Hepatomegaly, Bone Pain Crowd out cellular proliferation of other cells Nonfunctioning cells Weight Loss

Decreased WBC and Platelet

Anemia and Thrombocytopenia

Decreased defense against infection

Fever

Diagnostics

Hematology
WBC RBC
Hematocrit Hemoglobin Platelet Lymphocytes Monocytes Pt Result 360.7 2.49 0.21 106 535 0.12 0.14 Ref 9 5- 10 x 10 /L 4.5-6.0 x 12 10 /L .40-.54% 120-170 g/L 9 150-450x10 /L .20-.40 0-0.07

Diagnostics

Urinalysis

Physical Examination: Color: Yellow Transparency: Slightly Turbid Reaction 5.0 Specific Gravity: 1.025
Microscopic Examination: Pus Cells: 20-25 HPF Red Cells: 2-4 HPF Epithelial Cells: Few

Chronic Myeloid Leukemia

Risk for Infection

Subjective: Madalas akong magkaroon ng lagnat, ubo at sipon kahit nuon pa man, mga ilang buwan bago ako naconfine. as stated by the patient. Objective: Abnormally elevated WBC ( 360.7 x 109/L Decreased Lymphocytes and Monocytes

Risk for Infection

Risk for infection related to inadequate secondary defenses

Risk for Infection

After 8 hours of nursing intervention, patient will have reduced risk of local and systemic infection as evidenced by:
Understanding of causative risk factors Identification of interventions that reduces the risk of infection Compliance with preventive measures; and Prompt reporting of early signs and symptoms

Risk for Infection

INTERVENTIONS RATIONALE Pulmonary infections are common Many infections that occur in patient with leukemia are opportunistic due to immunocompression. Fever is a sign of infection and sometimes the first symptom to manifest Leukemic cells replace normal cells. This reduces transient and resident bacteria that may cause infection

ONGOING ASSESSMENT: Auscultate lung fields for crackles, ronchi and decreased lung sounds Inspect body sites with high infection potential
Monitor temperature as indicated

THERAPEUTIC INTERVENTIONS: Explain the cause and effect of leukopenia Instruct the client to maintain personal hygiene: hand washing, oral care and perineal care.

Risk for Infection

INTERVENTIONS RATIONALE

Instruct the patient and primary caregiver regarding the importance of eliminating potential sources of infection Avoidance of patient contact with family or visitor with flu Avoidance of shared drinking and eating utensils Instruct patient to wear face mask

Patient must understand the measures by which they can protect themselves during times of compromised defense

Risk for Infection

Goal met if After 8 hours of nursing intervention, patient have reduced risk of local and systemic infection as evidenced by:
Understanding of causative risk factors Identification of interventions that reduces the risk of infection Compliance with preventive measures; and Prompt reporting of early signs and symptoms

Fatigue
Subjective: Madali akong mapagod, katunayan kahit nakikipag-usap ako, ilang minuto lang nanghihina na ako. Objective: Hemoglobin = 106 g/L Weakness Exertional dyspnea

Fatigue

Fatigue related to reduced oxygen carrying capacity of blood as evidenced by report of weakness and exertional dyspnea

Fatigue
After 8 hours of nursing intervention, the patient will:
Report improved sense of energy Identify basis of fatigue an individual areas of control Establishes a pattern of sleep and rest that facilitates optimal performance of required or desired activities

Fatigue
INTERVENTIONS RATIONALE

Assist patient in planning ADLs. Not all self care activities need to Guide in prioritizing activities for the be completed in the morning day
Teach energy conservation principles Assist patient with self care needs ambulation as necessary Discuss routines to promote sleep Educate stress management skills of visualization, relaxation and biofeedback Instruct client to monitor responses to activity and significant signs and symptoms Sleep is important to regain energy To aid in establishing comfort and conditions conducive to relaxation Indicates the need to alter activity Patient may need to learn skills for delegation of task to others, setting priorities and clustering of activities

Fatigue
After 8 hours of nursing intervention, the patient:
Reported improved sense of energy Identified basis of fatigue an individual areas of control Established a pattern of sleep and rest that facilitates optimal performance of required or desired activities

Deficient Knowledge SUBJECTIVE: Ano ba talaga ang dahilan bakit ako nagkasakit ng ganito? As stated by the patient.

Deficient Knowledge

Deficient knowledge related to new disease

Deficient Knowledge After 4 hours of nursing interventions, the patient will verbalize understanding to the diseases:
Diagnosis Treatment Strategies; and Prognosis

Fatigue
INTERVENTIONS RATIONALE

ONGOING ASSESSMENT Assess knowledge of disease, Several types of leukemia occur treatment strategies and prognosis which can be confusing
THERAPEUTIC INTERVENTION Describe the etiology of leukemia These needs to be explained to the Explain the blood-forming changes patient to gain understanding of the that occur with all types of leukemia disease Clarify the difference between acute and chronic leukemia Describe the patients specific type of leukemia

Deficient Knowledge After 4 hours of nursing interventions, the patient verbalized understanding to the diseases:
Diagnosis Treatment Strategies; and Prognosis

Calcium Carbonate

Antacid, calcium supplement, osteoporosis

Calcium Carbonate

Decreases total acid load of GI tract. Increase esophageal sphincter tone

Calcium Carbonate

Hypercalcemia bone tremors severe renal failure hypersensitivity

Calcium Ceftriaxon e Carbonate PRECAUTION: History of stone formation, pregnancy

ADVERSE RXN Constipation, flatulence, diarrhea, renal dysfunction, acid rebound

Calcium Ceftriaxon e Carbonate administer as antacid 1 hr fter meal and at bed time administer as supplement 1 hrs after meal and at bed time advice pt to increase fluids to 2L unless contraindicated

Ceftriaxon e

Inhibits bacterial wall synthesis

Ceftriaxon e Gram negative infections; Meningitis, Gonorrhea. Bone and joint infections, Lower respiratory tract infections, middle ear infection, PID, Septicemia and Urinary Tract infections.

Ceftriaxon e

Patients hypersensitive to cephalosporins, penicillins and related antibiotics. Pregnancy (Category B). Breastfeeding women.

Ceftriaxon e phlebitis diarrhea, abdominal cramps, pseudomembranous colitis, biliary sludge Genital pruritus; moniliasis eosinophilia, thrombocytosis, leukopenia pain, indurations, tenderness, rash

Ceftriaxon e
determine hypersensitivity reactions periodic coagulation studies (PT and INR) should be done. inject in large muscles, such as gluteus maximus or lateral aspect of thigh and rotate sites. report signs such as petechiae, ecchymotic areas, epistaxis or other forms of unexplained bleeding. instruct to avoid alcohol use