ChronicMyeloid Leukemia

7/30/2019 ChronicMyeloid Leukemia

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P R E S E N T E D B Y :

J O H N J O S E P H O . D E G U Z M A N , R . N

J A Y B E E B E R N A N D I N O , R . N

C A T H Y T . R O X A S , R . N

Chronic Myeloid Leukemia



Patient’s 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 ordiabetes

Non-smoker Drinks alcohol during some occasions



does not have history of

hospitalization the past yearexcept for clinic visits due to cough andcold

May 2012, the patient observed easy fatigability and mild dyspnea when doing activities of daily living heused to do



July 13 2012, the patient experiencedsevere difficulty of breathing. Thefamily decided to seek medical attentionand brought him to a secondary levelhospital.

The hospital then referred the patient to atertiary level after administering

oxygen therapy and stabilizing his vitalsigns.

The doctor then ordered CBC, Xray,ECG and put him on oxygen and

complete bed rest without BRP



(input date)Laboratory findings and furtherassessments confirmed that patient has Chronic

Myeloid Leukemia and was then prompt forconfinement.

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 sttmntcnbi ntin n pnstop nia un chemo so i gues ok lng naadd toh. – un lng nmn =) sorry toxic ha! =p



Due to financial incapability , on

August 12, 2012, the patient askedthe physician to withdraw allchemotherapeutic 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 frequentcough and cold and seeks medical attention forsymptoms 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 mealusually has a balanced mix of fruits and vegetables with meat served seldom.Experienced weight loss of around 30kg in thelast 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 melenaprior 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 patientrequires 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 hefinds no difficulty sleeping



Nursing Assessment:Cognitive-Perceptual Pattern

Patient is able to read and write

Able to understand physician instructionsregarding 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 andfamily

If recovered, the patient expects a huge change of

lifestyle like wearing mask and strict infectionprecaution 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 hecould not interact with them as frequent as before



Nursing Assessment:Sexuality and Reproductive Pattern

The patient before admission assumes therole of a man thru being a father andhusband 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 cameto acceptance that he cannot provideanymore for the family



Nursing Assessment:Coping- Stress Tolerance Pattern

The patient have experienced many stressfulevents in the past and he responds thruconfronting the problem

With regards to family problems, he often talksto his wife or children before coming up with asolution



Nursing Assessment: Value-Belief Pattern

The patient is a Roman Catholic and believesthat God will never leave him throughout theillness

The illness does not interfere with his belief orreligious 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 theImmune System



Functions:

• Protection against invasion of microorganismfrom 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 immunesystem uses barriers to protect the body from foreign substances. These barriersinclude the skin and the mucous

membranes, which line all body cavities;and protective chemicals, such asenzymes in saliva and tears that destroy

bacteria. Another part of the immune

system uses lymphocytes, specialized white blood cells that respond to specifictypes of foreign invaders.



B LYMPHOCYTESPRODUCE PROTEINS

CALLED ANTIBODIES, WHICH CIRCULATE IN

THE BLOOD AND ATTACK SPECIFIC DISEASE-

CAUSING ORGANISMS. TLYMPHOCYTES ATTACK INVADING ORGANISMS

DIRECTLY.



First lines of defence

skin preventsentry

tears antibacterialenzymes

saliva antibacterialenzymes

stomach acid low pH killsharmfulmicrobes

mucus linings

traps dirt andmicrobes

“good” gutbacteria outcompete bad



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 targetspecific pathogens



Components

Macrophages

Lymphocytes



Lymphocytes

Lymphocytes are specialized white blood cells whosefunction 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 organlocated behind the breastbone.



Some T lymphocytes, called cytotoxic

(cell-poisoning) or killer T lymphocytes, generate cell-mediatedimmune responses, directly destroyingcells that have specific antigens on their

surface that are recognized by the killerT cells. Helper T lymphocytes, asecond kind of T lymphocyte, regulatethe immune system by controlling the

strength and quality of all immuneresponses.



Most contact between antigens and

lymphocytes occurs in the lymphoid organs—the lymph nodes, spleen, andtonsils, as well as specialized areas of theintestine and lungs (see Lymphatic

System). Mature lymphocytes constantly travel through the blood to the lymphoidorgans and then back to the blood again.This recirculation ensures that the body is

continuously monitored for invadingsubstances.



The Bone Marrow



The Bone Marrow

Bone Marrow, soft, pulpy tissue that fills the cavitiesof 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 adult’s weight. Redmarrow, present in all bones at birth, serves as the blood manufacturing center. As an infantmatures, 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 iscomposed 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-formingred marrow when the body needs more

blood



Pathoph siolog



Pathophysiology

Predisposing Factors:Possible Familial Tendency

Precipitating Factors:Exposure to Chemical Fertilizers

Myeloblast transformation

Continuous accumulation of immature cells

Splenomegaly,Hepatomegaly, BonePain

Crowd out cellularproliferation of other cells

Decreased WBC and

Platelet

Anemia andThrombocytopenia

Hypermetabolism

Weight LossNon-functioningcells

Decreased defense

against infection

Fever

Diagnostics



Diagnostics

Pt Result Ref

WBC 360.7 5- 10 x 109/L

RBC 2.49 4.5-6.0 x

10

12

/LHematocrit 0.21 .40-.54%

Hemoglobin 106 120-170 g/L

Platelet 535 150-450x10

9

/LLymphocytes 0.12 .20-.40

Monocytes 0.14 0-0.07

Hematology



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

Diagnostics



Chronic Myeloid Leukemia

Risk for



Subjective:

“Madalas akong magkaroon ng lagnat, ubo at sipon

kahit nuon pa man, mga ilang buwan bago ako na-

confine.” as stated by the patient.

Objective:

• Abnormally elevated WBC ( 360.7 x 109 /L

• Decreased Lymphocytes and Monocytes

Risk for

Infection

Risk for



Risk for infectionrelated to inadequate

secondary defenses

Risk for

Infection

Risk for



• 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

Risk for



INTERVENTIONS RATIONALE

ONGOING ASSESSMENT:

• Auscultate lung fields for crackles,

ronchi and decreased lung sounds

• Inspect body sites with high

infection potential

• Monitor temperature as indicated

• Pulmonary infections are common

• Many infections that occur in patient

with leukemia are opportunistic dueto immunocompression.

• Fever is a sign of infection and

sometimes the first symptom to

manifest

THERAPEUTIC INTERVENTIONS:

• Explain the cause and effect of

leukopenia

• Instruct the client to maintain

personal hygiene: hand washing,

oral care and perineal care.

• Leukemic cells replace normal

cells.

• This reduces transient and resident

bacteria that may cause infection

Risk for

Infection

Risk for




• Instruct the patient and

primary caregiver

regarding the importance

of eliminating potentialsources 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

Risk for



• 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

Risk for

Infection

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



Fatigue related to reduced oxygen

carrying capacity of blood as

evidenced by report of weakness

and exertional dyspnea

Fatigue

Fatigue



• After 8 hours of nursing intervention, thepatient 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

Fatigue



Fatigue


• Assist patient in planning ADLs.

Guide in prioritizing activities for the

day

• Not all self care activities need to

be completed in the morning

• Teach energy conservation

principles

• Patient may need to learn skills for

delegation of task to others, settingpriorities and clustering of activities

• Assist patient with self care needs

ambulation as necessary

• Discuss routines to promote sleep • Sleep is important to regain energy

• Educate stress management skills

of visualization, relaxation and

biofeedback

• To aid in establishing comfort and

conditions conducive to relaxation

• Instruct client to monitor responses

to activity and significant signs and

symptoms

• Indicates the need to alter activity

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

Fatigue

Deficient



SUBJECTIVE:

““ Ano ba talaga ang dahilan bakit ako

nagkasakit ng ganito?” As stated by thepatient.

Deficient

Knowledge

Deficient



Deficient knowledgerelated to new disease

Deficient

Knowledge

Deficient



• After 4 hours of nursing interventions,

the patient will verbalize

understanding to the disease’s:

•Diagnosis

•Treatment Strategies; and

•Prognosis

Deficient

Knowledge

Fatigue



Fatigue


ONGOING ASSESSMENT

• Assess knowledge of disease,

treatment strategies and prognosis

• Several types of leukemia occur

which can be confusing

THERAPEUTIC INTERVENTION

• Describe the etiology of leukemia• Explain the blood-forming changes

that occur with all types of leukemia

• Clarify the difference between acute

and chronic leukemia

• Describe the patient’s specific type

of leukemia

• These needs to be explained to thepatient to gain understanding of the

disease

Deficient



Deficient

Knowledge

• After 4 hours of nursing interventions,

the patient verbalized understanding

to the disease’s:

•Diagnosis

•Treatment Strategies; and

•Prognosis



Calcium



• Antacid, calcium

supplement,osteoporosis

Calcium

Carbonate

Calcium



• Decreases total acid load of GI

tract.

• Increase esophageal sphincter

tone

Calcium

Carbonate

Calcium



•Hypercalcemia

• bone tremors

•severe renal failure

• hypersensitivity

Calcium

Carbonate

Ceftriaxon

Calcium



• PRECAUTION:

• History of stone formation, pregnancy

• ADVERSE RXN

• Constipation, flatulence, diarrhea,

renal dysfunction, acid rebound

Ceftriaxon

e

Calcium

Carbonate

Ceftriaxon

Calcium



• administer as antacid 1 hr fter meal

and at bed time

• administer as supplement 1 ½ hrsafter meal and at bed time

• advice pt to increase fluids to 2L

unless contraindicated

•

Ceftriaxon

e

Calcium

Carbonate

Ceftriaxon



Inhibits bacterial wall

synthesis

Ceftriaxon

e

Ceftriaxon



Gram negative infections; Meningitis,

Gonorrhea. Bone and joint infections,

Lower respiratory tract infections,middle ear infection, PID, Septicemia

and Urinary Tract infections.

e

Ceftriaxon



Patients hypersensitive to

cephalosporins, penicillins and

related antibiotics. Pregnancy(Category B). Breastfeeding

women.

e

Ceftriaxon



• phlebitis

• diarrhea, abdominal cramps,

pseudomembranous colitis, biliarysludge

• Genital pruritus; moniliasis

• eosinophilia, thrombocytosis,leukopenia

• pain, indurations, tenderness, rash

e

Ceftriaxon



• determine hypersensitivity reactions

• periodic coagulation studies (PT and INR)should be done.

• inject in large muscles, such as gluteusmaximus or lateral aspect of thigh androtate sites.

• report signs such as petechiae, ecchymoticareas, epistaxis or other forms of unexplained bleeding.

• instruct to avoid alcohol use

e



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ChronicMyeloid Leukemia