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 Round in shape No tenderness

Normocepahlic No Lumps

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

SCALP No dandruff No Lumps noted

FACE Presence of
pimples noted,
No wrinkles,
brown in color

FOREHEAD Round, brown in No Lumps noted

color, No
wrinkles,
pimples noted

EYEBROWS Black in color, No Lumps noted

no lesions noted

EYELIDS Closes and opens No Mass noted

without difficulty

EYELASHES Equally
distributed
CONJUNCTIVA Pale, moist

SCLERA Opaque in color,

moist

PUPIL Pupil equally

round reactive to
light and
accommodation,
Constricts and
dilates

IRIS Dark brown in

color

LACRIMAL Pale, no
discharges

EXTRAOCULAR Moves without

EYE any difficulty,
MOVEMENT follows the six
cardinal gaze

LIPS Pale in color, No mass noted

symmetrical

MOUTH Gums are pale, No mass noted

fair in size, dry

TONGUE Pinkish in color,

whitish palate
present

TEETH Yellowish with a

complete set of
teeth

PALATE Hard and soft

palate are pale in
color

UVULA Rises upon

saying “ah”,
medially located
TONSILS Pale in color

NOSE Has discharges,

nasal mucus
noted, centrally
located, not
patent, septum
located medially,
no lesions, nasal
flaring was not
noted
EARS Symmetrical, ear
wax noted, can
hear clearly,
auricle aligned
with outer
canthus

NECK Brown in color, Carotid pulse: 78

symmetrical, can beats per minute,
perform ROM no lumps noted
exercises, lymph
nodes are not
inflamed

SKIN Brown in color,

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

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

CHEST Equal chest Vibration felt

expansion upon tactile
 RR: 24 breaths fermitus
per minute
BP: 100/60
HEART mmhg

Clear breath
sounds
LUNGS
Bowel sounds: 3
ABDOMEN Brown in color, upon
no abdominal auscultation
distention

LOWER: Can perform

limited ROM
exercises,
presence of
petechiae
(pinpoint like
appearance) on
his both legs
III. Nursing Assessment

1. Personal History

1.1Patients 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 14-17.5gm/dL 6.77gm/dL Decreased: Anemia
Increased:
Hematocrit 14-17.5 19.3
Erythrocytosis

4.4-11.0 174,000
WBC Increased: Infection
3% 02%
Band Decreased:
56% 05% Decreased:
Segmenter
0.3% --
Basophil NORMAL
2.7% --
Eosnophil NORMAL
34% 07%
Lymphocyte Decreased: Immuno –
deficiency
4% 61%
Increased: Viral
Monocyte
infections
4.5-5.9 10 12/L 1.93 10 12/L
Decreased: Anemia
RBC 80-96fL 100fL
Increased: Macrocytic
MCV
Anemia
27.5-33.2pg 35.1 pg
Increased: : Macrocytic
MCH Anemia
33.4-35.5% 35.0%
NORMAL
MCHC --
--
-- -- NORMAL
MPV
150,000- NORMAL
RDW 27,020/cu mm
Platelet Count 450,000/cu mm Decreased: Acute
Leukemia

--
0.5-1.5%
--
Reticulocyte NORMAL
0.00-20.00mm/h
2.1 mg/dL NORMAL
ESR 0.7-1.5mg/dL
3.0 mmol/L Increased: Fever
Creatinine Serum 3.6-5.0mmol/L
59 uL Decreased: Diarrhea
Potassium 11-66uL
134 mmol/L
ALT 137-145mmol/L
NORMAL
Sodium Decreased: Metabolic
11.9 mg/L
2.5-7.5mg/L Acidosis
Increased: Gout
Uric Acid
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

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

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 CLINICAL SYMPTOMS RATIONALE

SYMPTOMS
Anemia Manifested More specific signs and

symptoms of acute
• Dyspnea During the assessment,
myelogenous leukemia
• Fatigue the student nurse
are caused by a lack of
observed that the
• Pale skin,
properly functioning
patient has a pale skin,
mucous
blood cells, resulting
oral mucosa,
membrane,
from overcrowding by
conjunctiva and nail
conjunctiva,
leukemia cells. The
beds. The patient also
nail beds
oxygen carrying
verbalizes that he feels
capacity of hemoglobin
weak and sometimes he
is reduced causing
had difficulty in
tissue hypoxia and can
breathing even doing
result to fatigue,
things with no exerted
weakness and dyspnea
force.

(p. 276 disease

management for nurse

practitioner by: Scilling)

In acute melogenous

leukemia, there is the

Thrombocytopenia loss of bone marrow

Manifested
function because of the

The patient had a low replacement of the

platelet count levels malignant cells such as

 (27,020cu mm) 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
• Bleeding Manifested
platelets or impaired
One week prior to
platelet function.
admission, the patient
Bleeding that results
experiences hematuria
from platelet deficiency
and bloody stools. The
commonly occurs in
patient also has
small vessels and is
petechiae in his
characterized by
surrounding skins.
petechae and purpura

(p. 265 disease

management for nurse

practitioner by: Scilling)

 In acute myelogenous

leukemia, the bone

marrow produces

immature cells that

Manifested usually develop into a

type of abnormal white

Neutropenia The patient was advised
blood cell. These
by his physician to wear
• infection abnormal cells aren't
mask all the time and
able to mature and
must eat foods that ca
perform their usual
boost his immune
functions. Even worse,
system
they multiply rapidly

and can crowd out

healthy cells, leaving a

person with acute

myelogenous leukemia

vulnerable to infection

(http://www.mayoclinic.c

om)

The symptoms of AML

are caused by low

numbers of healthy

blood cells and high

Manifested
numbers of leukemia
The patient had fever
• fever one week prior to his cells. White blood cells

admission because of fight infection. Low

massive tonsillitis numbers can 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

Manifested are often a source of

infection; therefore a
The patient complains of
complain of a sore
having difficulty in
throat is an important of
 • tonsillitis swallowing because of early indication of a

tonsillitis. potential problem

(p. 660 Davis’s NCLEX-

RN Success by:

Lagerquist)

These is because of the

proliferation of leukemia

cells within organs

Not Manifested (p. 897 medical- surgical

nursing by: Brunner)

Not Manifested

Not Manifested

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 METHODOL EVALUA-
OGY 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. predisposing factors in Informal
1. identify acquiring leukemia discussion
predisposing 1.1 expose to radiation for a
factors in long period
acquiring 1.2 genetic factors such as
leukemia down syndrome
1.3 exposure to chemicals
such as benzene and
drugs that causes aplasic
anemia
Informal
2. signs and symptoms of discussion
2. enumerate leukemia
signs and 2.1 fever and infection
symptoms of related to decrease in
leukemia white blood cells
2.2 weakness and fatigue
from anemia
2.3 bleeding tendencies from
decreased platelets
3. determine the
significance 3. significance on wearing Informal
on wearing a mask all the time discussion
mask all the 3.1 this is to prevent the
time patient from acquiring
any infection
4. the patient will 4. shows interest during the Informal
show interest health teaching discussion and
during the 4.1 asks questions during the utilization of
health interaction of the student pictures
teaching 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
activities
5. demonstrate 5.1 teach client on how to Scheduling
beginning cluster activities to activities and
skills on prevent fatigue example: Informal
preventing Monday: 7:00-7:30 discussion
fatigue by (eating breakfast)
clustering 7:30 – 9:00 watching
scheduled television for relaxation
activities 9:00-9:30 perform
exercise such as walking
9:30-10:00 reading
books …
5.2 let the patient decide
and schedule his planned activities
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” 7th 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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