I. Introduction

I personally selected this case of Acute Myelogenous Leukemia (AML) to

enhance my knowledge concerning its clinical manifestations, possible causes,

cure and prevention, among others. This knowledge will eventually become an

indispensable tool that can be shared to others and will never go out of style. It is

a privilege to embrace this challenge in the form of service to humanity and the

fulfillment of our nursing profession. Our core competence is the bare essential

towards its success.

As a nursing profession, it is imperative to learn new techniques in

modern science in order to develop skills that would benefit the medical world.

This learning potential must be relayed to posterity and develop new techniques,

state -of –the- art technology that caters the modern man. In the final analysis, the

achievement of one’s endeavor may usher us to find the light we are seeking for.

First of all what is leukemia? Leukemia is a cancer of the blood, and is

characterized by uncontrolled proliferation and accumulation of leukocytes (white

blood cells). Most leukemic cells never mature into functioning leukocytes.

Where in the body is deprived of vital components of its immune system. Also,

the cells accumulate in the blood and in certain organs, forcing out healthy cells

and interfering with the function of that organ. There many different types of

leukemia but the four most important forms are derived from only two types of

cells, lymphocytes and myelocytes. Acute myelogenous leukemia is disorders of

granulocytes. Granulocytes produced by bone marrow, engulf and digest bacteria

and other small particles. This generally appears suddenly with symptoms like

those of cold, and progresses rapidly. The lymph nodes, spleen and liver may

become infiltrated with leukocytes and enlarged. There is often bone pain,

paleness due to anemia, a tendency to bleed easily because of depleted platelets

and high susceptibility to infections. The most common causes of death, which

occurs on the average within three months if without treatment, are hemorrhaging

and uncontrolled infections. Acute myelogenous leukemia occurs much less

frequently in children.

II. Objectives

General Objectives:

After 3 days of giving holistic care, the patient will be able to regain optimum

level of functioning and adopt coping skills in performing activities of daily living.

Specific Objectives:

After 8 hours of giving holistic nursing care, the patient will be able to:

1. establish rapport with the student nurse

2. explain reasons of hospitalization

3. state past medical history related to present condition

4. identify the precipitating and predisposing factors that can possibly lead to the occurrence

of the condition

5. discuss the management applied upon the occurrence of the disease

After 8 hours of giving holistic care, the student nurse will be able to:

1. establish rapport with the patient

2. present the patient’s personal history

3. assess the patient’s level of growth and development

4. show present profile of functional health patterns

5. discuss with the patient the different predisposing and precipitating factors

6. identify the pathophysiology and rationale

7. construct a comprehensive nursing care plan appropriate for the patient

8. discuss different measures for home management

PHYSICAL ASSESSMENT

Body Parts Inspection Palpation Percussion Auscultation

HEAD

HAIR

SCALP

FACE

FOREHEAD

EYEBROWS

EYELIDS

EYELASHES

CONJUNCTIVA

SCLERA

PUPIL

Round in shapeNormocepahlic

Evenly distributed, Black in color, short, straight hair, smooth

No dandruff

Presence of pimples noted, No wrinkles, brown in color

Round, brown in color, No wrinkles, pimples noted

Black in color, no lesions noted

Closes and opens without difficulty

Equally distributed

Pale, moist

Opaque in color, moist

Pupil equally round reactive to light and accommodation, Constricts and

No tendernessNo Lumps

No Lumps noted

No Lumps noted

No Lumps noted

No Mass noted

IRIS

LACRIMAL

EXTRAOCULAR EYE MOVEMENT

LIPS

MOUTH

TONGUE

TEETH

PALATE

UVULA

TONSILS

NOSE

dilates

Dark brown in color

Pale, no discharges

Moves without any difficulty, follows the six cardinal gaze

Pale in color, symmetrical

Gums are pale, fair in size, dry

Pinkish in color, whitish palate present

Yellowish with a complete set of teeth

Hard and soft palate are pale in color

Rises upon saying “ah”, medially located

Pale in color

Has discharges, nasal mucus noted, centrally located, not patent, septum located medially, no lesions, nasal flaring was not noted

No mass noted

No mass noted

EARS

NECK

SKIN

EXTREMITIES: UPPER:

CHEST

HEART

LUNGS

ABDOMEN

Symmetrical, ear wax noted, can hear clearly, auricle aligned with outer canthus

Brown in color, symmetrical, can perform ROM exercises, lymph nodes are not inflamed

Brown in color, petechiae was noted in both lower and upper extremities (pin point like appearance), Temperature of 36.8 degree Celsius

Without IV, can perform limited ROM exercises, petechiae was noted (pin point like appearance)

Equal chest expansionRR: 24 breaths per minute

Brown in color, no abdominal

Carotid pulse: 78 beats per minute, no lumps noted

Vibration felt upon tactile fermitus

BP: 100/60 mmhg

Clear breath sounds

Bowel sounds: 3 upon

LOWER:

distention

Can perform limited ROM exercises, presence of petechiae (pinpoint like appearance) on his both legs

auscultation

III. Nursing Assessment

1. Personal History

1.1 Patients Profile

Name: Mr. Abella, Fernando

Age: 50 years old

Sex: Male

Civil Status: Married

Religion: Roman Catholic

Date of Admission: February 04, 2007

Room No. : 532

Complaints: tonsillitis

Diagnosis: Acute Myelogenous Leukemia

Physician: Dr. Ponce, Susie

1.2Family and individual information, social and health history

Mr. Abella, Fernando, 50 yrs. Old, male, Filipino Roman Catholic, who is married and has four

children, all of which are still schooling. The patient works in a government office. The patient is always

exposed in petroleum products and paints. Mr. Abella is not hypertensive, diabetic and asthmatic. He is

an occasional drinker and a positive smoker which he consumes one pack per day. Mr. Abella was

rushed in the emergency room of Cebu Doctor’s University Hospital because he fainted and was very

pale. He also complains of tonsillitis.

1.3. Level of growth and Development

Normal Development at Particular Stage

The patient belongs to the middle adulthood. The middle years, from 40 – 65, have been

called the years of stability and consolidation. For most people, it is a time when children have grown

and moved away or are moving away from home. Thus, partners generally have more time for and with

each other and time to pursue interests they may have deferred for years.

The middle adulthood, the individual makes lasting contributions through involvement

with others. During this period, personal and career achievements have often already been experienced.

Many middle adults find particular joy in assisting their children and other young people to become

productive and responsible adults. They may also begin to help aging parents. Using leisure time in

satisfying and creative ways is a challenge that, if met satisfactory, enables middle adults to prepare for

retirement.

Men and women must adjust to inevitable biological changes. As in adolescence, middle

adults use considerable energy to adapt self concept and body image to physiological realities and

changes in physical appearance. High self-esteem, a favorable body image, and a positive attitude

toward physiological changes are fostered when adults engage in physical exercise, balanced diet,

adequate sleep, and good hygiene practices that promote vigorous, healthy bodies.

Physical Changes

A number of changes take place during the middle years. At 40, most adults can function

as they did in their twenties. However during ages 40 – 65, many physical changes takes place. Both men

and women experience decreasing hormonal production during the middle years. The menopause refers

to the so called change of life in women, when menstruation ceases. It is said to have occurred when a

woman has not had a menstrual period within a year. The menopause usually occurs anywhere between

ages 40 – 55. The average is about 47 years. At this time, the ovaries decrease in activity until ovulation

ceases. Psychologically, the menopause can be anxiety- producing time, especially if the ability to bear

children is an integral part of woman’s self concept. The hair begins to thin and gray hair appears. Skin

turgor and moisture decrease, subcutaneous fat decreases and wrinkling occur. Fatty tissue is

redistributed, resulting in fat deposits in the abdominal area. Skeletal muscle bulk decreases at about

age 60. Thinning of the intervertebral disk causes a decrease in height of about 1 inch. Calcium loss from

bone tissue is more common among postmenopausal women. Muscle growth continues in proportion to

use. Blood vessels lose elasticity and become thicker. Visual acuity declines, often by the late forties,

especially for near vision (presbyopia). Auditory acuity for high- frequency sounds (presbycusis) also

decreases, particularly in men. Taste sensations also diminish. Metabolism slows, resulting in weight

gain. Gradual decrease in tone of large intestine may predispose the individual to constipation. Nephron

units are lost during this time, and glomerular filtration rate decreases. Hormonal changes take place in

both men and women.

Cognitive Changes

The middle- aged adults’ cognitive and intellectual abilities change very little. Cognitive

processes include the action time, memory, perception, learning, problem solving, and creativity.

Reaction time during the middle years stays much the same or diminishes during the later part of the

middle years. Memory and problem solving are maintained through middle adulthood. Learning

continuous and cab be enhanced by increased motivation at this time in life.

Middle-aged adults are able to carry out all the strategies described in Piaget’s phase of

formal operations. The experiences of the professional, social, and personal life of middle-aged persons

will be reflected in their cognitive performance. Thus, approaches to problem solving and task

completion will vary considerably in middle-aged group. The middle-aged adult can “reflect on the past

and current experience and can imagine, anticipate, plan and hope”.

Changes in the cognitive function of middle adults are rare except with illness are

trauma. The middle adult can learn new skills and information. Some middle adults enter educational or

vocational programs to prepare themselves for entering the job market or changing jobs.

Moral Changes

During this stage, rules and laws are valued because they maintain social order worth

preserving. Morality is guided by higher principles of human conduct. Individuals appreciate the social

purposes served by laws. They believe laws should be derived from a democratic consensus. Individuals

search their own conscience for universal ethical principles. They do not make up their own rules but

instead arrive at abstract principles that all religions or moral authorities might view as compelling or

fair. There is a correlation between higher stages of reasoning and higher levels of moral behavior.

According to Kohlberg, the adult can move beyond the conventional level to the post

conventional level. Kohlberg believes that extensive experience of personal moral choice and

responsibility is required before people can reach the post conventional level. Kohlberg found that few

of his subjects achieved the highest level of moral reasoning.

Psychosocial Development

The psychosocial changes in the middle adult may involve expected events, such as

marital separation. This change may result in stress that can affect the middle adults’ over all level of

health. In the middle adult years, as children depart from the household, the family enters the post

parental family stage. Time and financial demands on the parents decrease, and the couple faces the

task of redefining their own relationship. According to Eriksons’ developmental theory, the primary

developmental task of the middle years is to achieve generativity. Generativity is the willingness to care

for and guide others. If middle adults fail to achieve generativity, Stagnation occurs. This is shown by

excessive concern with themselves or destructive behavior toward their children and community.

Spiritual Changes

As man grows older he becomes more aware of the outside world. Some conform when they

are forced to do so, some are driven by self interests and will do only what they must do to get what

they want in return. They violate God’s law regularly, sinning more or less everyday with little remorse.

Their spiritual senses are not alert. They are ignorant of God and have no concept of holiness. But as

man grows older, he becomes more conscious of how important people really are. “Being good” is now

important. He thinks about how other people see him and how they must feel. He realizes that the

world runs according to rules. The desire to please other drives him and when he fails his first response

is to justify himself. This faith is based on the beliefs of the community.

In adult life many individuals develop a faith that is purely their own individual faith and

can deal with the paradoxes and ironies of human existence. A final stage of development finds some

individuals making a commitment to universal values, such as love and justice. The focus on the value of

experience and reflection and intellectual development finds a strong parallel in the importance given to

the rule of experience and reflection in spiritual growth.

Sexuality Changes

After the departure of their last child from the home, many couples recultivate their

relationships and find increased marital and sexual satisfaction during middle age. The onset of

menopause and the climacteric can affect the sexual satisfaction during the middle adult. Other factors

influencing sexuality during this period include work stress, diminished health of one or both partners,

and the use of prescription medications.

Diagnostic Test Normal Value Result Significance

Hemoglobin

Hematocrit

WBC

Band

Segmenter

Basophil

Eosnophil

Lymphocyte

Monocyte

RBC

MCV

MCH

MCHC

MPV

RDW

Platelet Count

Reticulocyte

ESR

Creatinine Serum

Potassium

ALT

Sodium

14-17.5gm/dL

14-17.5

4.4-11.0

3%

56%

0.3%

2.7%

34%

4%

4.5-5.9 10 12/L

80-96fL

27.5-33.2pg

33.4-35.5%

--

--

150,000-450,000/cu

mm

0.5-1.5%

0.00-20.00mm/h

0.7-1.5mg/dL

3.6-5.0mmol/L

11-66uL

137-145mmol/L

6.77gm/dL

19.3

174,000

02%

05%

--

--

07%

61%

1.93 10 12/L

100fL

35.1 pg

35.0%

----

27,020/cu mm

----

2.1 mg/dL

3.0 mmol/L

59 uL

134 mmol/L

Decreased: AnemiaIncreased: Erythrocytosis

Increased: Infection

Decreased:

Decreased:

NORMAL

NORMAL

Decreased: Immuno –

deficiency

Increased: Viral

infections

Decreased: Anemia

Increased: Macrocytic

Anemia

Increased: : Macrocytic Anemia

NORMAL

NORMAL

NORMAL

Decreased: Acute Leukemia

NORMAL

NORMAL

Increased: Fever

Decreased: Diarrhea

NORMAL

Decreased: Metabolic

Acidosis

Uric Acid 2.5-7.5mg/L 11.9 mg/L Increased: Gout

Present Profile of the Functional Health Patterns

3.1 Health Perception Pattern

Before the patient was diagnosed with Acute Myelogenous Leukemia the patient

describes himself as a healthy individual. But as of now, he describes his condition as very poor due to

his present condition. In order for him to keep healthy, he must eat nutritious foods and must not over

fatigue himself. He follows the doctors order and take the medication as needed. The patient refuses to

have chemotherapy due to financial problems.

3.2 Nutritional Metabolic Pattern

Before the patient was not admitted in the hospital, he likes to eat any kind of foods.

But as of now, the patient does not want to eat and he vomits all the time. The patient drinks alcohol

mostly everyday, he prefers to drink Tanduay and Emperador. The patient also smokes and can consume

one pack per day. The patient takes vitamin supplements like Revicon and Everet. According to the

patient his weight had decreased from 180 pounds to 110 pounds.

3.3 Elimination Pattern

On the first week of his admission, the patient was having hematuria and melena. After

the following weeks, the patient’s foley bag catheter was already removed and the patient was

having no problems in urinating and defecating. The patient defecates once in a day.

3.4 Activity or Exercise Pattern

Before, the patient used to walk from his home to his office, but now even five steps he feels

fatigue and will have a difficulty in breathing. The patient was advised by the physician not to over

fatigue himself and he needs enough sleep and rest.

3.5 Cognitive or Perceptual Pattern

The patient cannot see from far objects. He wears eyeglasses so that he can see clearly. The

patient can hear well enough. The patient often times complains of fatigue and feels drowsy all the time.

The patient is able to read and write.

3.6 Sleep or rest Pattern

Before the patient’s hospitalization, he sleeps at 7: 00 pm to 6:00 in the morning, but

now because of his condition he sleeps most of the time. The patient has no problem in sleeping.

3.7 Self Perception Pattern

The patient is concerned about his illness. He is scared that he will die and might be far

away from his family. According to the patient, he wants to be free from Leukemia but it is too

impossible to happen, it needs some miracles. The patient describes himself as very religious especially

with his condition and he must need some faith to hold on to whatever circumstances might happen. His

condition made him different because unlike normal people he needs to wear a mask all the time.

3.8 Role Relationship Pattern

The patient prefers to speak Cebuano. He speaks clearly and fluently and he is able to

express himself freely. The patient lives with his family in Matab-ang Toledo City.

3.9 Coping or stress Tolerance Pattern

The patient and his wife both make the decision especially when it comes to health and

financial matters. He sometimes seeks help to his mother when it comes t o problem solving because he

is more comfortable in asking for assistance so that he can express his feelings. The patient is still

working but he will just go to work to punch in and leave.

3.10 Value or belief System

The patient is a Roman Catholic and God is very important to him. For him, God and his

family is his source of strength and meaning. The patient prays the rosary and attends mass every

Sunday. The patient wishes to go to Simala to pray for his condition. According to the patient, he just

accepts what Gods plan awaits him.

IV. Pathophysiology and Rationale

Anatomy and Physiology

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 disease-causing organisms. T lymphocytes attack invading

organisms directly.

COMPONENTS OF THE IMMUNE SYSTEM

Macrophage Engulfing Bacterium

A macrophage, in yellow, engulfs and consumes a bacterium. Macrophages are large

phagocytes, cells 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 (literally, “cell eating”), 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.

LYMPHOCYTE

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, the soft tissue that fills most bone

cavities, but they mature in two different places. Some lymphocytes mature in the bone marrow and are

called B lymphocytes. B lymphocytes, or B cells, make antibodies, which circulate through the blood and

other body fluids, binding to antigens and helping to destroy them in humoral immune responses.

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 organs—the 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.

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 adult’s 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.

STRUCTURE

Red marrow consists primarily of a loose, soft network of blood vessels and protein

fibers interspersed with developing blood cells. The blood vessels are termed the vascular

component, and the protein fibers and developing blood cells collectively are referred to as the

stroma, or the extravascular component. The protein fibers crisscross the marrow, forming a

meshwork that supports the developing blood cells clustered in the spaces between the fibers.

Red marrow contains a rich blood supply. Arteries transport blood containing oxygen and

nutrients into the marrow, and veins remove blood containing carbon dioxide and other wastes.

The arteries and veins are connected by capillaries, blood vessels that branch throughout the

marrow. In various places, the capillaries balloon out, forming numerous thin, blood-filled

cavities. These cavities are called sinusoids, and they assist in blood-cell production.

Yellow marrow is so named because it is composed of yellow fat cells interspersed in a

rich mesh of connective tissue that also supports many blood vessels. 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

MARROW FUNCTION

Red marrow produces all of the body’s blood cells—red blood cells, white blood cells,

and platelets. Red blood cells in the circulatory system transport oxygen to body tissues and

carbon dioxide away from tissues. White blood cells are critical for fighting bacteria and other

foreign invaders of the body .Platelets are essential for the formation of blood clots to heal

wounds. Within red bone marrow, all blood cells originate from a single type of cell, called a

hematopoietic stem cell. Stimulated by hormones and growth factors, these stem cells divide to

produce immature, or progenitor blood cells. Most of these progenitor cells remain in the stroma

and rapidly undergo a series of cell divisions, producing either red blood cells or white blood

cells. At any one time, the stroma consists largely of progenitor cells in various stages of

development. At the appropriate developmental stage, the fresh, new cells squeeze through the

walls of the capillaries. From there, the cells leave the bone and enter the body’s circulatory

system. Some progenitor cells migrate to the sinusoids, where they produce platelets, which also

travel to the circulatory system via the capillaries. Although stem cells are relatively rare—about

1 in every 10,000 marrow cells is a stem cell—they typically produce the forerunners of an

estimated 2 million red cells per second and 2 billion platelets per day. However, if significant

amounts of blood are lost or other conditions reduce the supply of oxygen to tissues, the kidneys

secrete the hormone erythropoietin. This hormone stimulates stem cells to produce more red

blood cells. To fight off infection, hormones collectively termed colony stimulating growth

factors are released by the immune system. These hormones stimulate the stem cells to produce

more infection-fighting white blood cells. And in severe cases, the body converts yellow marrow

into red marrow to help produce needed blood cells.

PREDISPOSING FACTORS

4.3 Discuss the disease process ands its effects on different organ/system

Leukemia Overview

CANCER

Canc er 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

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.

Each type of blood cells has its own different and essential function in the body.

White blood cells (leukocytes) are part of the immune system and help fight a variety of

infections. They also help in the healing of wounds, cuts, and sores.

Red blood cells (erythrocytes) contain hemoglobin, which carries oxygen to, and removes

carbon dioxide from, the cells throughout the various organs of the body.

Platelets, along with certain plasma proteins, help plug the holes in blood vessels and form clots

once blood vessels are damaged or cut.

The first step in the process of stem cell maturation is differentiation into 2 groups: the myeloid stem

cell line and the lymphoid stem cell line.

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. Leukemias that

affect the lymphoid lineage are called lymphocytic (also lymphoblastic or lymphogenous)

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 or

a few months.

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.

WHAT HAPPENS IN LEUKEMIA?

When a large number of blasts (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 are 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 (the white blood cell count). 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 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.

Cancer cells Normal cells

ACUTE MYELOGENOUS LEUKEMIA

A PICTURE OF ACUTE MYELOGENOUS LEUKEMIA

Acute myelogenous leukemia (AML) is a cancer of the blood and bone marrow — the spongy

tissue inside bones where blood cells are made.

It's called acute leukemia because it progresses rapidly and affects immature blood cells,

rather than mature ones. It's called myelogenous (MI-uh-loj-uh-nus) leukemia because it affects a

group of white blood cells called the myeloid cells, which normally develop into the various

types of mature blood cells, such as red blood cells, white blood cells and platelets. This type of

leukemia is also known as acute myeloid leukemia, acute myeloblastic leukemia, acute

granulocytic leukemia and acute nonlymphocytic leukemia.

Normally, your bone marrow produces immature cells (stem cells) in a controlled way, and they

mature and specialize into the various types of blood cells as needed. In people with acute

myelogenous leukemia, the bone marrow produces immature cells that usually develop into a

type of abnormal white blood cell. These abnormal cells aren't able to mature and perform their

usual functions. Even worse, they multiply rapidly and can crowd out healthy cells, leaving a

person with acute myelogenous leukemia vulnerable to infection, anemia or easy bleeding.

Leukemia cells can also spread outside the blood to other parts of your body.Acute myelogenous

leukemia is the most common form of leukemia. It worsens quickly if not treated, but it initially

responds well to treatment. Unfortunately, many people with acute myelogenous leukemia

experience a relapse. Much research is focused on decreasing the risk of relapse and improving

the long-term outcomes for people with acute myelogenous leukemia

CAUSES

The cause of acute myelogenous leukemia 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. Other genes, called tumor suppressor genes, slow down 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 cells 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, damage to 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).

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 in females. Other possible

risk factors include:

Cancer therapy. People who've had certain types of chemotherapy and radiation therapy or

treatment for childhood acute lymphocytic leukemia (ALL) may have a greater risk of developing

AML.

Exposure to radiation and certain chemicals. People exposed to very high levels of radiation,

such as survivors of an atomic bomb 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 the chemical industry — also is 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 that nonsmokers do.

Other blood disorders. People who've had another blood disorder, such as myelodysplasia,

polycythemia vera or thrombocythemia, are at greater risk of developing AML.

Genetic disorders. Certain genetic disorders, such as Down syndrome, are associated with an

increased risk of AML.

CLASSICAL SYMPTOMS CLINICAL SYMPTOMS RATIONALE

Anemia

Dyspnea

Fatigue

Pale skin, mucous

membrane,

conjunctiva, nail beds

Manifested

During the assessment, the

student nurse observed that

the patient has a pale skin,

oral mucosa, conjunctiva and

nail beds. The patient also

verbalizes that he feels weak

and sometimes he had

difficulty in breathing even

doing things with no exerted

force.

More specific signs and

symptoms of acute

myelogenous leukemia are

caused by a lack of properly

functioning blood cells,

resulting from overcrowding

by leukemia cells. The oxygen

carrying capacity of

hemoglobin is reduced

causing tissue hypoxia and

can result to fatigue,

weakness and dyspnea

(p. 276 disease management

for nurse practitioner by:

Thrombocytopenia

Bleeding

Manifested

The patient had a low platelet

count levels (27,020cu mm)

Manifested

One week prior to admission,

the patient experiences

hematuria and bloody stools.

The patient also has petechiae

in his surrounding skins.

Scilling)

In acute melogenous

leukemia, there is the loss of

bone marrow function

because of the replacement of

the malignant cells such as

occurs in leukemia, which

results in decrease production

of platelets

(p. 265 disease management

for nurse practitioner by:

Scilling)

In acute myelogenous

leukemia, bleeding is evident

because of a decrease

circulating platelets or

impaired platelet function.

Bleeding that results from

platelet deficiency commonly

occurs in small vessels and is

characterized by petechae

and purpura

(p. 265 disease management

Neutropenia

infection

Manifested

The patient was advised by his

physician to wear mask all the

time and must eat foods that

ca boost his immune system

for nurse practitioner by:

Scilling)

In acute myelogenous

leukemia, the bone marrow

produces immature cells that

usually develop into a type of

abnormal white blood cell.

These abnormal cells aren't

able to mature and perform

their usual functions. Even

worse, they multiply rapidly

and can crowd out healthy

cells, leaving a person with

acute myelogenous leukemia

vulnerable to infection

(http://www.mayoclinic.com)

The symptoms of AML are

caused by low numbers of

healthy blood cells and high

numbers of leukemia cells.

White blood cells fight

infection. Low numbers can

fever

Manifested

The patient had fever one

week prior to his admission

because of massive tonsillitis

lead to fever and frequent

infections. With

immunosuppression the body

the body is often unable to

respond an infection with a

characteristic indicator, such

as fever

(http://www.marrow.org)

(p. 660 Nursing Care of

acutely ill and chronically ill

patient by: Lagerquist)

In patient who is immune-

suppressed, the oral mucous

membranes are often a

source of infection; therefore

a complain of a sore throat is

an important of early

indication of a potential

problem

(p. 660 Davis’s NCLEX- RN

tonsillitis

Manifested

The patient complains of

having difficulty in swallowing

because of tonsillitis.

Not Manifested

Not Manifested

Not Manifested

Success by: Lagerquist)

These is because of the

proliferation of leukemia cells

within organs

(p. 897 medical- surgical

nursing by: Brunner)

Spleenomegaly

Hyperplasia of the gums

Bone pain

Nursing Interventions

1. Care Guide in Patient with disease Condition

TREATMENT

Treatment of patients with acute myelogenous leukemia depends on age and the subtype of

the disease. In general, treatment falls into two phases:

Remission induction therapy. The purpose of the first phase of treatment is to kill the leukemia

cells in your blood and bone marrow. However, remission induction usually doesn't wipe out all

of the leukemia cells, so you need further treatment to prevent the disease from returning.

Consolidation therapy. Also called post-remission therapy, maintenance therapy or

intensification, this phase of treatment is aimed at destroying the remaining leukemia cells. It's

considered crucial to decreasing the risk of relapse.

Therapies used in these phases include:

Chemotherapy. Chemotherapy is the major form of remission induction therapy. A

common course of therapy involves two chemotherapy drugs — cytarabine (Cytosar-U),

followed by an anthracycline drug, such as daunorubicin (Cerubidine) or idarubicin

(Idamycin). A third medication, thioguanine, is sometimes used.

If you have AML, you'll probably stay in the hospital during the treatment cycle because

the chemotherapy destroys many normal blood cells in the process of killing leukemia

cells. This chemotherapy can cause anemia, infection and bleeding. If the first cycle of

treatment doesn't cause remission, you may need it repeated one or two more times. Other

drug combinations also may be used, depending on your specific situation.

Chemotherapy can also be used for consolidation therapy. This phase may include a

combination of different medications that mimic the induction, but usually includes high

doses of cytarabine by itself for one to three cycles. Your doctor may also prescribe

medications that boost white cell production to reduce the risk of infection. These

medications are called granulocyte colony stimulating factors (Neupogen, Leukine).

Other drug therapy. Arsenic trioxide and all-trans retinoic acid (ATRA) are anti-cancer drugs that

can be used alone — or in combination with chemotherapy — for remission induction of a

certain subtype of AML called promyelocytic leukemia. These drugs cause leukemia cells with a

specific gene mutation to mature and die, or to stop dividing.

Biological therapy. Also known as immunotherapy, biological therapy uses substances that

bolster your immune system's response to cancer. Monoclonal antibodies are one form of

biological therapy. These antibodies are produced in a laboratory, but they mimic protein

products found in your immune system (antibodies) that attack foreign substances (antigens) on

leukemic cells. Gemtuzumab ozogamicin (Mylotarg) is a monoclonal antibody linked to a

chemical toxin that attaches to AML cells. It's used to treat older people with AML who don't

respond to initial treatment or who relapse after successful initial treatment. Researchers are

testing its effectiveness in younger people with AML.

Bone marrow transplant. This is another option for consolidation therapy for people at high risk

of relapse or for treating relapse when it occurs. This procedure allows someone with leukemia

to re-establish healthy stem cells by replacing their leukemic bone marrow with leukemia-free

marrow. If you choose this treatment, you'll receive very high doses of chemotherapy or

radiation therapy to destroy your leukemia-producing bone marrow. This marrow is then

replaced by bone marrow from a compatible donor (allogeneic transplant). In some cases, you

may also be able to use your own bone marrow for transplant (autologous transplant). This is

possible if you go into remission and then save healthy bone marrow for a future transplant.

Stem cell transplant. Stem cell transplant is also used for consolidation therapy. It's similar to

bone marrow transplant except the stem cells are collected from circulating blood (peripheral

blood), rather than from the bone marrow, thanks to a medication that causes larger numbers

of stem cells to be released from the bone marrow. The cells used for transplant can be your

own healthy cells, or they can be collected from a compatible donor. This procedure is used

more frequently than bone marrow transplant because of shortened recovery times and

possible decreased risk of leukemia recurrence.

Radiation Therapy.Radiation therapy involves the use of radiation to kill cancer cells

and shrink tumors. For AML, external radiation therapy is used.In external radiation

therapy radiation is directed at the tumor from a source outside the body. This type of

treatment is used for AML that has spread—or may spread—to the brain and spinal cord.

It can also be used to treat bone pain that comes from bone affected by the leukemia.

NCP

s- “ dali na kayo ko kutasan ug kapuyan na ko dae, mga lima ka lakang kapuyon na ko” as verbalized by

the patient

o- weakness

-feeling of exhaustion

-low RBC counts: 1.93

- low hemoglobin count: 6.77

-shortness of breath

-fatigue

-blood pressure: 100/60 mmhg

A- Activity Intolerance: fatigue related to anemia

P- demonstrate a decrease in physiologic signs of intolerance

I- plan care with rest periods between activities

elevate head of bed as tolerated

provide positive atmosphere, while acknowledging difficulty of the situation of the patient

provide quiet environment, maintain bed rest as indicated. Limit visitors, phone calls and reported unplanned interruptions

prioritize nursing care schedules to enhance rest.

use energy techniques such as shower chair, sitting performing task

provide assistance with patient, including activities that the patient views as essential. Increase activity levels as tolerated

instruct patient to stop activity if palpitations, chest pains, shortness of breath, weakness, dizziness occur

change patient position slowly and monitor for dizziness

E- the patient shows a decrease signs of intolerance

s- “ ingon si doc dae na pa mason ko niya kai para dili ko ma takdan sa mga sakit”

As verbalized by the patient

o- increase white blood cells:174,000

presence of immature leukocytes

compromised immunity

wears mask

low eosinophil: 0%

low lymphocyte: 07%

A- Risk for infection related to proliferation of immature lymphocytes

P- the client will be free from acquiring infection

I- maintain a fluid intake of at least 2500 ml per day

use good handwashing technique and encourage patient to do the same

protect client from others with infections

instruct and assist client to perform good oral hygiene as often as needed

instruct patient to wear mask all the time

eliminate fresh salads and unpeeled fresh fruits and vegetables

allow no fresh flowers

administer antimicrobials as needed

E- the patient shows a decrease signs of intolerance

s- “ pait kaau ning akong kahimtang, naa pa koi mga anak nga gagmay sa tanan ako pa jd wala mn me

kwarta” As verbalized by the patient

o- sad facial expression

crying

A- Anticipatory grieving related to possible loss of loved one

P- will be able to express feelings of anxiety

I- encourage verbalization of fears, concerns and questions regarding disease treatment

encourage active participation of patient or family in care and treatment decisions

be with patient most of the times

encourage verbalization of negative feelings, including anger and hostility

allow periods of crying and expression of sadness

use therapeutic communication skills of active listening, silence, acknowledgement

advise for professional counseling

permit verbalization of anger with acknowledgement of feelings and setting of limits regarding destructing behavior

E- the patient was able to verbalize feelings of anxiety

OBJECTIVES CONTENTS METHODOLOGY

EVALUA-TION

GOAL: After 3 days of varied teaching and learning experience, the patient and significant others will be able to gain knowledge, attitude and skills about his disease condition and how to prevent fatigue.

After 45 minutes of student nurse-patient interaction, the patient will be able to:

1. identify predisposing factors in acquiring leukemia

2. enumerate signs and symptoms of leukemia

1. predisposing factors in acquiring leukemia1.1 expose to radiation for a

long period1.2 genetic factors such as

down syndrome1.3 exposure to chemicals

such as benzene and drugs that causes aplasic anemia

2. signs and symptoms of leukemia2.1 fever and infection

related to decrease in white blood cells

Informal discussion

Informal discussion

3. determine the significance on wearing a mask all the time

4. the patient will show interest during the health teaching

5. demonstrate beginning skills on preventing fatigue by clustering scheduled activities

2.2 weakness and fatigue from anemia

2.3 bleeding tendencies from decreased platelets

3. significance on wearing mask all the time3.1 this is to prevent the

patient from acquiring any infection

4. shows interest during the health teaching4.1 asks questions during the

interaction of the student nurse

4.2 participates and encourages the student nurse to go on to the discussion

4.3 Shows interest on the discussion by cooperating with the student nurse

5. clustering scheduled activities5.1 teach client on how to

cluster activities to prevent fatigue example:Monday: 7:00-7:30 (eating breakfast)7:30 – 9:00 watching television for relaxation9:00-9:30 perform exercise such as walking9:30-10:00 reading books …

5.2 let the patient decide and schedule his planned activities

Informal discussion

Informal discussion and utilization of pictures

Scheduling activities and Informal discussion

VII. Evaluation and Recommendation:

Early detection of an ailment is vital to the patient. Oftentimes lack of in-depth

knowledge regarding a condition of a disease may hinder a patient in seeking immediate advice

from medical specialist. Fear and financial problems may sometimes interfere which may often

lead to the severity of the disease.

This I believe is one of the major causes as to why my patient has gone to this terminal

stage of his Acute Myelogenous Leukemia (AML). The nature of his job as a painter exposes

him to great risk of an organ damage. Petroleum products when exposed to a person to a

considerable period of time may often lead a person to this problem. This is also coupled with

lack of knowledge regarding this health hazard.

According to his recent laboratory results, his platelet is 27,000 /cu mm which is very

low compared to the normal platelet count of 150,000-450,000/ cu mm. This shows a decrease in

both platelets and erythrocytes. The patient shows hematuria, melena and petechiae on his both

upper and lower extremities, this is an indication of decrease in platelet as well. Because of lack

of mature and normal granulocytes, the patient had a massive tonsillitis. Since treatment for

chemotherapy is too costly for the patient this could contribute for a compelling severity of his

health condition.

It is necessary to undertake sessions of chemotherapy to prolong the patient’s life.

Immaturity of leukocytes can also lead to severe infection, the patient is encouraged to wear

mask whenever the condition necessitates. The patient needs proper rest due to fatigue. He also

needs more encouragement from his immediate family member, relatives and friends.

Government sector plays a great role in sustaining financial support for indigent patients.

Health care institutions can also help in the financial assistance of their members. Advancement

of medical technology and profession is always a mileage in the science of medical world.

DTR

VII. Bibliography

Porth, Carolwatson.” Pathophysiology”.6th edition.

Schilling, Judith A. RN, MSN “ Disease management for Nurse Practitioners”.

Smeltzer, Suzanne. Bare, Brenda. “Medical-Surgical Nursing. 10th edition. Lippincott Wiliams and Wilkins.

Lagerquist, Sally. “ Nclex-RN Success” F.A. Davis Company

Marieb, Elaine. “Essentials of Human Anatomy and physiology” 7 th edition.Pearon

education Inc., San Francisco, California. 2003.

Smeltzer. Bare. “ Medical-Surgical Nursing”. 10th edition.

Patrick. “ Medical-Surgical Nursing”. 2nd edition.

Phipps. Long. Woods. “Medical-Surgical Nursing”

INTERNET:

http://healthgate.partners.org

www.mayoclinic.com

www.cancerlinkusa.com

www.niaid.nih.gov]

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