Chapter I

Introduction

Objectives of the Study:

a. General objectives

To be able to gain more knowledge about leukemia especially about

Acute Myelogenous Leukemia, know the difference of AML among other
leukemias and learn more chemptheraphy

b. Specific objectives

 To expand our knowledge about the signs and symptoms of

Acute Myelogenous Leukemia
 To know the pathophysiology of Acute Myelogenous
Leukemia
 To know the proper nursing management of AML by learning
the proper interventions to be rendered to patients with
Acute Myelogenous Leukemia
 To know how AML is diagnosed and the important laboratory
examinations that will confirm AML
 To know the nursing priorities to consider when dealing with
patients of AML especially when patient is undergoing
chemotherapy

1
DESCRIPTION OF THE CASE

Alternative names of Acute myelogenous leukemia: AML; Acute

granulocytic leukemia; Acute nonlymphocytic leukemia (ANLL); Leukemia - acute
myeloid (AML); Leukemia - acute granulocytic; Leukemia - nonlymphocytic
(ANLL) Acute myelogenous leukemia (AML), is a fast-growing cancer of the
blood and bone marrow. In AML, the bone marrow makes many unformed cells
called blasts. Blasts normally develop into white blood cells that fight
infection. However, the blasts are abnormal in AML. They do not develop and
cannot fight infections. The bone marrow may also make abnormal red blood
cells and platelets. The number of abnormal cells (or leukemia cells) grows
quickly. They crowd out the normal red blood cells, white blood cells and
platelets the body
needs./http://www.cancercenter.com/acute_myelogenous_leukemia.cfm/

The word "acute" in acute myelogenous leukemia denotes the disease's

rapid progression. 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. /http://www.mayoclinic.com/health/acute-myelogenous-
leukemia/DS00548/

Acute Myelogenous Leukemia is a trending health concern in the

Nursing profession because of dangers of treatment which is the
chemotherapy. According to the article, “The Truth About Chemotherapy - It
Is Dangerous”, Chemotherapy can cause heart problems, destroy bile ducts,
cause bone tissue death, restrict growth, cause infertility, lower white and red cell
counts and lead to intestinal and lactose malabsorption.
 After all, and for the overwhelming majority of the cases, there is no proof
whatsoever that chemotherapy prolongs survival expectations. And this is the

2
great lie about this therapy, that there is a correlation between the reduction of
cancer and the extension of the life of the patient." (Philip Day, "Cancer: Why
we're still dying to know the truth"). /http://www.articlesbase.com/cancer-
articles/the-truth-about-chemotherapy-it-is-dangerous-906032.html/

As implied from the article above, chemotherapy has so many

dangerous effects and it as a trending health concern to the Nursing
Profession. Side effects may be acute (short-term), chronic (long-term), or
permanent. Side effects may cause inconvenience, discomfort, serious illness
and even death. Additionally, certain side effects may prevent doctors from
delivering the prescribed dose of chemotherapy at the specific time and schedule
of the treatment plan. Side effects from chemotherapy can include
pain, diarrhea, constipation, mouth sores, hair loss, nausea and vomiting, and
blood-related side
effects. /http://www.chemotherapy.com/side_effects/side_effects.html/

As nurses we should be knowledgeable about chemotherapy since it has

so many dangerous side effects. We should update ourselves about how could
we alleviate the pain brought about by the side effects chemotherapy.
Chemotherapy is yet controversial because some researchers believed that
chemotherapy cannot really prolong life and can cause death.

3
BACKGROUND OF THE STUDY

 Alfred-Armand-Louis-Marie Velpeau described a 63-year-old florist who

developed an illness characterized by fever, weakness, urinary stones, and
substantial enlargement of the liver and spleen. Velpeau noted that the blood of
this patient had a consistency "like gruel", and speculated that the appearance of
the blood was due to white corpuscles. In 1845, a series of patients who died
with enlarged spleens and changes in the "colors and consistencies of their
blood" was reported by the Edinburgh-based pathologist J.H. Bennett; he used
the term "leucocythemia" to describe this pathological condition. Further
advances in the understanding of acute myeloid leukemia occurred rapidly with
the development of new technology. In 1877, Paul Ehrlich developed a technique
of staining blood films which allowed him to describe in detail normal and
abnormal white blood cells. Wilhelm Ebstein introduced the term "acute
leukemia" in 1889 to differentiate rapidly progressive and fatal leukemias from
the more indolent chronic leukemias .The term "myeloid" was coined by
Neumann in 1869, as he was the first to recognize that white blood cells were
made in the bone marrow (Greek: µυєλός, myelos = (bone) marrow) as
opposed to the spleen. The technique of bone marrow examination to diagnose
leukemia was first described in 1879 by Mosler. Finally, in 1900 the myeloblast,
which is the malignant cell in AML, was characterized by Naegeli, who divided
the leukemias into myeloid and lymphocytic.
/http://en.wikipedia.org/wiki/Acute_myeloid_leukemia#History/.

Cancer is the third leading cause of morbidity and mortality in the

Philippines. Leading cancer sites/types are lung, breast, cervix, liver, colon and
rectum, prostate, stomach, oral cavity, ovary and
leukemia. /http://jjco.oxfordjournals.org/content/32/suppl_1/S52.full/. Incidence
rates for all types of leukemia are higher among males than among
females. In 2010, males are expected to account for more than 57 percent of the

4
new cases of leukemia. The most common types of leukemia in adults are
acute myelogenous leukemia (AML), with an estimated 12,330 new cases in
2010. Leukemia is one of the top 10 most frequently occurring cancers in
all races or ethnicities. Leukemia incidence is highest among whites (12.9 per
100,000) and lowest among American Indians/Alaskan natives (6.5 per
100,000), Asian and Pacific Islander populations (7.2 per
100,000). /http://www.leukemia-lymphoma.org/all_page?item_id=9346/.

Some people with acute myeloid leukemia (AML) have one or more known
risk factors but most do not. The cause of their cancer remains unknown at
this time. Even when a person has one or more risk factors, there is no way to
tell whether it actually caused the cancer. During the past few years, scientists
have made great progress in understanding how certain changes in DNA can
cause normal bone marrow cells to become leukemia cells. Normal human cells
grow and function based mainly on the information contained in each cell's
chromosomes. Chromosomes are long molecules of DNA in each cell. DNA is
the chemical that makes up our genes -- the instructions for how our cells
function. We resemble our parents because they are the source of our DNA. But
our genes affect more than the way we look.
/http://www.cancer.org/Cancer/LeukemiaAcuteMyeloidAML/DetailedGuide/leuke
mia-acute-myeloid-myelogenous-what-causes/

There are certain risk factors for AML. Smoking is the only proven
lifestyle-related risk factor for AML. Many people know that smoking is linked to
cancers of the lungs, mouth, throat, and larynx (voice box), but few realize that it
can also affect cells that don't come into direct contact with smoke. Cancer-
causing substances in tobacco smoke are absorbed by the lungs and spread
through the bloodstream to many parts of the body. The risk of AML may be
increased by exposure to certain chemicals. Long-term exposure to high levels
of benzene is a risk factor for AML. Benzene is a solvent used in the rubber

5
industry, oil refineries, chemical plants, shoe manufacturing, and gasoline related
industries, and is also present in cigarette smoke, and some glues, cleaning
products, detergents, art supplies, and paint strippers. Radiation exposure,
High-dose radiation exposure (such as being a survivor of an atomic bomb blast
or nuclear reactor accident) increases the risk of developing AML. Japanese
atomic bomb survivors had a greatly increased risk of developing acute
leukemia, usually within 6 to 8 years after exposure. Patients with certain blood
disorders seem to be at increased risk for getting AML. These include
chronic myeloproliferative disorders such as polycythemia vera, essential
thrombocytopenia, and idiopathic myelofibrosis. Chronic myelogenous leukemia
(CML) is another type of myeloproliferative disorder, and some patients with CML
later develop a form of AML. The risk of developing AML is increased further if
treatment for these disorders includes some types of chemotherapy or radiation.
Congenital syndromes (present at birth) For the most part, acute myeloid
leukemia does not appear to be an inherited disease. It is rare for it to run in
families, so a person's risk is not usually increased if a family member has the
disease. But there are some congenital syndromes with genetic changes that
seem to raise the risk of AML. These include; Down syndrome, Fanconi-anemia
Bloom syndrome, Ataxia-telangiectasia, and Blackfan-Diamond syndrome.
Having an identical twin with AML, this risk is largely confined to the first year
of life. Most cases of AML are not thought to have a strong genetic link. Many
doctors feel the increased risk among identical twins may be due to leukemia
cells being passed from one fetus to the other while still in the womb. Other
factors that have been studied for a possible link to AML include; Exposure to
electromagnetic fields (such as living near power lines), Workplace exposure to
diesel, gasoline, and certain other chemicals and solvents and also exposure to
herbicides or
pesticides./http://www.cancer.org/Cancer/LeukemiaAcuteMyeloidAML/DetailedG
uide/leukemia-acute-myeloid-myelogenous-risk-factors/

6
 Certain signs and symptoms might suggest that a person may have
acute myeloid leukemia (AML), but tests are needed to confirm the
diagnosis. Blood samples for tests for AML are generally taken from a vein
in the arm. Bone marrow samples are obtained from 2 tests that are usually
done at the same time: The samples are usually taken from the back of the
pelvic (hip) bone, but sometimes other bones are used instead. If only an
aspiration is to be done, it may be taken from the sternum (breast bone).In
bone marrow aspiration, you lie on a table (either on your side or on your
belly). The doctor will clean the skin over the hip and then numb the area and
the surface of the bone with a local anesthetic. This may cause a brief stinging
or burning sensation. A thin, hollow needle is then inserted into the bone and a
syringe is used to suck out a small amount of liquid bone marrow (about 1
teaspoon). Even with the anesthetic, most patients still have some brief pain
when the marrow is removed. A bone marrow biopsy is usually done just
after the aspiration. A small piece of bone and marrow (about 1/16 inch in
diameter and 1/2 inch long) is removed with a slightly larger needle that is
twisted as it is pushed down into the bone. This causes a pressure feeling,
and rarely may also cause some brief pain. Once the biopsy is done, pressure
will be applied to the site to help prevent bleeding. These bone marrow tests
are used to help diagnose leukemia. They may also be repeated later to tell if
the leukemia is responding to treatment. Spinal fluid, the cerebrospinal fluid
(CSF) is the liquid that surrounds the brain and spinal cord. Leukemia can
spread to the area around the brain and spinal cord. To check for this spread,
doctors remove a sample of CSF for testing. The procedure used to remove a
sample of this fluid is called a lumbar puncture (spinal tap). One or more of the
following lab tests may be done on the samples to diagnose AML and/or to
determine the specific subtype of AML. The complete blood count (CBC) is a
test that measures the different cells in the blood, such as the red blood cells,
the white blood cells, and the platelets. This test is often done along with a

7
differential (or diff) which looks at the numbers of the different types of white
blood cells. For the peripheral blood smear, a sample of blood is looked at
under the microscope. These tests look at how the different types of cells in
the blood appear under the microscope and how many of them there are.
Changes in the numbers and the appearance of these cells often help
diagnose leukemia.

A key element is whether the cells look mature (like normal blood
cells) or immature (lacking features of normal blood cells). The most
immature cells are called myeloblasts (or "blasts" for short).The percentage of
cells in the bone marrow or blood that are blasts is particularly important. Having
at least 20% blasts in the marrow or blood is generally required for a
diagnosis of AML. It can also be diagnosed if the blasts have a chromosome
change that occurs only in a specific type of AML, even though the blast
percentage doesn't reach 20%. Sometimes the blasts look similar to normal
immature cells in the bone marrow. But under normal circumstances, blasts are
never more than 5% of bone marrow cells. In order for a patient to be considered
to be in remission after treatment, the blast percentage must be no higher than
5%.

For cytochemistry tests, cells are exposed to chemical stains (dyes) that
react with only some types of leukemia cells. These stains causes color changes
that can be seen under a microscope, which can help the doctor determine what
types of cells are present. For instance, one stain can help distinguish AML cells
from acute lymphocytic leukemia (ALL) cells. The stain causes the granules of
most AML cells to appear as black spots under the microscope, but it does not
cause ALL cells to change colors.

Imaging tests use x-rays, sound waves, magnetic fields, or radioactive

particles to create pictures of the inside of the body. Leukemia does not usually
form visible tumors, so imaging tests are of limited value. There are several

8
imaging tests that might be done in people with AML, but they are done more
often to look for infections or other problems, rather than to look for the leukemia
itself. In some cases imaging tests may be done to help determine the extent of
the disease, if it is thought it may have spread beyond the bone marrow and
blood. These imaging test are x-ray, CT scan, MRI, ultrasound , gallium scan and
bone scan.
/http://www.cancer.org/Cancer/LeukemiaAcuteMyeloidAML/DetailedGuide/leuke
mia-acute-myeloid-myelogenous-diagnosed/

Typically AML comes on suddenly, within days or weeks. Less often, a

patient has been ill for a few months or may have a prior history
of Myelodysplastic Syndrome. AML makes people sick primarily by interfering
with normal bone marrow function. The leukemia cells replace and crowd out the
normal cells of the bone marrow, thereby causing low blood cell counts. This
insufficient number of red blood cells results in a condition called anemia, which
causes a person to be tired and pale. Lack of platelets can make you more
susceptible to bleeding and bruising, especially in the skin, nose and gums.
Lowered levels of normal white blood cells increase the risk of infection. Although
infections can be of any type, typical symptoms include: fever, runny nose,
cough, Chest pain or shortness of breath, pain with urinating, diarrhea,
occasionally, infections of the bloodstream, called sepsis, and pneumonia are the
most dangerous. General signs and symptoms of the early stages of acute
myelogenous leukemia may mimic those of the flu or other common
diseases. Signs and symptoms may vary based on the type of blood cell
affected. Signs and symptoms of acute myelogenous leukemia include, fever,
bone pain, lethargy and fatigue, shortness of breath, pale skin, frequent
infections, easy bruising, unusual bleeding, such as frequent nosebleeds and
bleeding from the
gums./http://www.mayoclinic.com/health/acutemyelogenousleukemia/DS00548/D
SECTION=symptoms/

9
 Medical management includes chemotherapy and use of anti-neoplastic
agents. Patients with AML need to start chemotherapy right away. It is
important to get medical care in a center where doctors are experienced in
treating AML patients. There are two parts of AML treatment, called induction
therapy and consolidation therapy.  The aim of induction therapy is to kill as
many AML cells as possible and get blood cell counts back to normal over time.
When the aim of induction therapy is achieved it is called a remission. A
patient in remission feels better over time and leukemia cells can't be seen in his
or her blood or marrow. Induction therapy is done in the hospital. Patients are
often in the hospital for three to four weeks. Some patients may need to be in the
hospital longer. Many different drugs are used to kill leukemic cells. Each drug
type works in a different way to kill the cells. Combining drug types can
strengthen the effects of the drugs. New drug combinations are being studied.
Two or more chemotherapies are usually used together to treat AML. Some
drugs are given by mouth. Most chemotherapies are given through
a catheter placed into a vein, usually in the patient's upper chest. The first round
of chemotherapy usually does not get rid of all the AML cells. Most patients will
need more treatment. Usually the same drugs are used for more rounds of
treatment to complete induction therapy. More treatment is usually needed even
after a patient with AML is in remission. This second part of treatment is called
consolidation therapy. It is needed because some AML cells remain that are
not found by common blood or marrow tests. Consolidation therapy is also done
in the hospital. As with induction therarpy, patients may be in the hospital
for three to four weeks, or sometimes longer. Consolidation therapy may include
chemotherapy with or without an allogeneic stem cell transplant or autologous
stem cell transplant. /http://www.leukemia-lymphoma.org/all_page.adp?
item_id=8459#treatment/

10
 Nursing management are directed towards relieveing the signs and
symptoms of AML and managing the side effects of chemotherapy. Side effects
such as neutropenia, thrombocytopenia, anemia, mucositis, gastritis, nausea,
vomiting, diarrhea, constipation, central nervous system alterations, knowledge
deficit and ineffective coping. Preventing infection, frequently monitor the client
for pneumonia, pharyngitis, esophagitis, perianal cellulitis, urinary tract infection,
and cellulitis, which are common in leukemia and which  carry significant
morbidity and mortality. Monitor for fever, flushed appearance, chills, tachycardia;
appearance of white patches in the mouth; redness, swelling, heat or pain in the
eyes, ears, throat, skin, joints, abdomen, rectal and perineal areas; cough,
changes in sputum; skin rash. Check results of granulocyte counts.
Concentrations less than 500/mm3 put the patient at serious risk for infection.
Avoid invasive procedures and trauma to skin or mucous membrane to prevent
entry of microorganisms. Use the following rectal precautions to prevent
infections: Avoid diarrhea and constipation, which can irritate the rectal mucosa,
avoid the use of rectal thermometers, and keep perineal are clean. Care for the
patient in private room with strict handwashing practice. Encourage and assist
patient with personal hygiene, bathing, and oral care. Obtain cultures and
administer antimicrobials promptly as directed. Preventing and Managing
bleeding: Watch for signs of minor bleeding, such as petechiae, ecchymosis,
conjunctival hemorrhage, epistaxis, bleeding gums, bleeding at puncture sites,
vaginal spotting, heavy menses. Be alert for signs of serious bleeding, such as
headache with change in responsiveness, blurred vision, hemoptysis,
hematemesis, melena, hypotension, tachycardia, dizziness. Test all urine, stool,
emesis for gross and occult blood. Monitor platelet counts daily. Administer blood
components as directed. Keep patient on bed rest during bleeding episodes.
Patient Education and Health Maintenance: Teach signs and symptoms of
infection and advise whom to notify. Encourage adequate nutrition to prevent

11
emaciation from chemotherapy. Teach avoidance of constipation with increased
fluid and fiber, and good perineal care. Teach bleeding precautions. Encourage
regular dental visits to detect and treat dental infections and
disease. /http://nursingcrib.com/case-study/leukemia-case-study/

Cancer is largely a preventable illness. Two-thirds of cancer deaths in

the U.S. can be linked to tobacco use, poor diet, obesity, and lack of exercise. All
of these factors can be modified. Nevertheless, an awareness of the opportunity
to prevent cancer through changes in lifestyle is still under-appreciated. The
majority of cases of AML cannot be prevented since we do not know the cause.
The few cases associated with benzene exposure are preventable with better
workplace conditions. The exact number of cases of AML that could be
prevented by avoiding exposure to automobiles is unknown, but this is
impractical for the majority of people. Diet is a fertile area for immediate
individual and societal intervention to decrease the risk of developing certain
cancers. Numerous studies have provided a wealth of often-contradictory
information about the detrimental and protective factors of different foods. There
is convincing evidence that excess body fat substantially increases the risk for
many types of cancer. While much of the cancer-related nutrition information
cautions against a high-fat diet, the real culprit may be an excess of calories.
Studies indicate that there is little, if any, relationship between body fat and fat
composition of the diet. These studies show that excessive caloric intake from
both fats and carbohydrates lead to the same result of excess body fat. The ideal
way to avoid excess body fat is to limit caloric intake and/or balance caloric
intake with ample exercise. It is still important, however, to limit fat intake, as
evidence still supports a relationship between cancer and polyunsaturated,
saturated and animal fats. Specifically, studies show that high consumption of
red meat and dairy products can increase the risk of certain cancers. One
strategy for positive dietary change is to replace red meat with chicken, fish, nuts

12
and legumes. High fruit and vegetable consumption has been associated with a
reduced risk for developing at least 10 different cancers. This may be a result of
potentially protective factors such as carotenoids, folic acid, vitamin C,
flavonoids, phytoestrogens and isothiocyanates. These are often referred to as
antioxidants. There is strong evidence that moderate to high alcohol consumption
also increases the risk of certain cancers. One reason for this relationship may
be that alcohol interferes with the availability of folic acid. Alcohol in combination
with tobacco creates an even greater risk of certain types of cancer. Exercise,
higher levels of physical activity may reduce the incidence of some cancers.
According to researchers at Harvard, if the entire population increased their level
of physical activity by 30 minutes of brisk walking per day (or the equivalent
energy expenditure in other activities), we would observe a 15% reduction in the
incidence of colon
cancer. /https://www.texasoncology.com/showtypescancer.aspx?
documentid=757/

13
 Chapter II

Review of Related Literature

What is Acute Myelogenous Leukemia?

“Decoding of a Acute Myeloid Leukemia Genome”

http://www.suite101.com/content/decoding-of-a-acute-myeloid-leukemia-
genome-a77999#ixzz1AFvxkBHa

Acute Myeloid Leukemia (AML) is a cancer of the white blood cells and
characterized by a rapid proliferation of abnormal cells. These cancerous cells
accumulate in the bone marrow and interfere with the production of normal white
or red blood cells. When cancerous blood cells accumulate in the blood or bone
marrow, infection, anemia, or easy bleeding can frequently occur. The leukemia
cells can spread outside the blood to other parts of the body, including to organs
of the central nervous system such as brain and spinal cord.

How is AML diagnosed?

‘Hope After a Cancer Diagnosis”Anti-viral Drug Ribavirin Shows Promise in

CancerTreatment
http://www.suite101.com/content/hope-after-a-cancer-diagnosis-
a117732#ixzz1AG28qciK

Cancer drugs targeting the eukaryotic translation initiation factor gene

offers hope in cancer treatment.
Getting a cancer diagnosis can be overwhelming but there is hope in the form the
anti-viral drug, ribavirin. This according to a recent clinical trial and study
conducted on a group of cancer patients. Cancerous cells multiply without any
14
cell regulation creating tumors and growths. This is commonly caused by a
genetic mutation within a cancerous cell’s DNA. Scientists have been able to
pinpoint the source to some specific genes within the cell’s genetic code. One
commonly found gene mutation in cancer patient’s cancerous cells is within the
gene regulation of eIF4E protein. This gene is found to be impaired in about a
third of the different cancers; namely breast, colon, stomach and prostate.

How is AML treated?

“Researchers discover key mutation in acute myeloid leukemiaNIH-
supported discovery may lead to treatment changes”
http://www.wellsphere.com/cancer-article/researchers-discover-key-
mutation-in-acute-myeloid-leukemianih-supported-discovery-may-lead-to-
treatment-changes-demonstrates/1275566

Researchers discover key mutation in acute myeloid leukemia

NIH-supported discovery may lead to treatment changes; demonstrates power of
The Cancer Genome Atlas strategy Researchers have discovered mutations in a
particular gene that affects the treatment prognosis for some patients with acute
myeloid leukemia (AML), an aggressive blood cancer that kills 9,000 Americans
annually. The scientists report their results in the Nov. 11, 2010, online issue
of The New England Journal of Medicine.The Washington University School of
Medicine in St. Louis team initially discovered a mutation by completely
sequencing the genome of a single AML patient. They then used targeted DNA
sequencing on nearly 300 additional AML patient samples to confirm that
mutations discovered in one gene correlated with the disease. Although genetic
changes previously were found in AML, this work shows that newly discovered
mutations in a single gene, called DNA methyltransferase 3A or DNMT3A,
appear responsible for treatment failure in a significant number of AML
patients.  The finding should prove rapidly useful in treating patients and which

15
may provide a molecular target against which to develop new drugs. 
Mutations in AML
“Mutations in Single Gene Predict Poor Outcomes in Adult Leukemia;
Discovery May Guide Treatment for Acute Myeloid Leukemia”
http://www.sciencedaily.com/releases/2010/11/101110171337.htm

ScienceDaily (Nov. 11, 2010) — Decoding the DNA of a woman who died of
acute myeloid leukemia (AML) has led researchers at Washington University
School of Medicine in St. Louis to a gene that they found to be commonly altered
in many patients who died quickly of the disease.
The findings, if confirmed in larger studies, suggest that a diagnostic test for
mutations in the gene could identify AML patients who need more aggressive
treatment right from the start. The new discovery also provides a concrete target
for developing improved therapies against AML, a fast-moving blood cancer that
kills 9,000 Americans annually.
Studying nearly 300 AML patients, the researchers found those with a mutation
in the DNA methyltransferase 3A gene, or DNMT3A, survived for a median of just
over one year after their diagnosis, compared with nearly 3.5 years for those
without a mutation. The research is published online Nov. 10 in the New England
Journal of Medicine.

Chemotherapy for AML

“Intensive Chemotherapy May Be Harmful to Most Older Patients With
Acute Myeloid Leukemia”
http://www.sciencedaily.com/releases/2010/07/100729091458.htm
ScienceDaily (July 29, 2010) — The prognosis for nearly three-quarters of elderly
patients on intensive chemotherapy for acute myeloid leukemia (AML) is poor,
with a median survival of less than six months, according to a study published
online in Blood, the journal of the American Society of Hematology.

16
Recent studies have suggested that intensive chemotherapy might benefit elderly
patients with AML, but we found that not to be the case," said Hagop Kantarjian,
MD, Chairman of the Leukemia Department at The University of Texas M. D.
Anderson Cancer Center in Houston and senior author of the study. "Patients
who did not have any of the eight-week mortality predictors we identified in the
study may benefit from the more intense treatment, but for the majority of AML
patients of advanced age, lower-intensity treatments are a better, less risky
option."Symptoms of AML include fever, frequent infections, tiredness, pale skin,
shortness of breath, easy bleeding or bruising, and pain in the bones or joints.
Because the disease develops rapidly, doctors usually begin treatment
immediately after diagnosis. Treatments for AML include chemotherapy or a
transplant with blood cells obtained from the circulating blood or cord blood,
though, for most elderly patients, the risks of serious side effects eliminate
transplant as a viable option.

17
 Chapter III
Client Presentation
PATIENT PROFILE

Name: (alyas) “Kiko”

Age: 24 years old
Birthday: August 03, 1986
Address: Imus, Cavite
Nationality: Filipino
Civil Status: Single
Religion: Roman Catholic
Admission: November 11, 2010 @ 11:00 a.m
Chief Complaint: Easy fatigability and sudden weight loss
Admitting Physician: Dr. R. Espinoza
Hospital: St. Luke’s Medical Center
Ward: Private Room
Admitting Diagnosis: Stage 4 Acute Myelogenous Leukemia
Weight upon admission: 125lbs/56.82kg
Height: 5’8
Blood type: type A
Blood Pressure upon admission: 80/50mmhg

Past Medical History

The patient was diagnosed of anemia when he was 13 years old and was
prescribed to take iron supplements. He took the iron supplements for 3 years.
Upon entering college he discontinued taking his medications. He finished B.S.
accountancy and worked as a bank accountant in Banco de Oro branch in Manila
for 3 years. During these years, he often experience flu, cough and colds. He
also often experience easy fatigability upon doing ADLs.

Present

The present illness has begun 6 months ago with sign and symptoms of
easy fatigability, presence of bruise in some areas of the body and sudden weigh
loss of 2 kilograms in 2 weeks which prompt the patient to seek medical
consultation. He had undergone certain laboratory examination such as blood
cell tests and bone marrow test. He was then advised to undergo chemotherapy
because he was diagnosed of Stage 4 of Acute Myelogenous Leukemia.

18
The 13 Areas of Assessment
I. Psychosocial Status

The patient is a Caviteño and was raised by his parents in their

province. He worked as a bank accountant in Banco De Oro branch in
Manila. They live in a concrete house. He is Roman Catholic. The
patient is the youngest among the brood of three. His father died two
years ago because of leukemia. The patient is 24 years old and single.
His family supports him in his treatment. According to his mother, he
loves to spend his time with his family.

II. Mental and Emotional Status

The patient is conscious, he can still respond to verbal stimuli,

and has some decreased deep tendon reflexes. He is oriented to time,
place and can recognize people around him.

The patient is a degree holder so he can easily follow

instructions. He has a good memory and can recall things in the past.

The patient is depressed about her condition and he has lost hope
in recovering from his illness. He is afraid that any time he may die.
Sometimes he cry at night and at times he gets mad at his family
because he feels like they don’t do their best to alleviate his condition.

NURSING DIAGNOSIS:

ANXIETY r/t current condition of illness as manifested by

verbalization of feelings of hopelessness and fear of the unknown

ANTICIPATORY GRIEVEING r/t loss of hope to survive his

illness as manifested by periods of crying and expression of
sadness.

III. Emotional Status

The patient is 24 years old, he is mobile and was placed in a

private room. The patient is immunosuppressed so the health
personnel and significant others are observing for strict isolation
precaution. The patient’s watcher is his mother. He is not manifesting
any infectious disease and has no presence of infected wound in his
skin. His mother and significant others as well the health personnel,

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 are observing proper hand washing before, during and after contact
with the patient. The patient is wearing a mask every time he goes out
of his room assisted by his mother. He practices meticulous personal
hygiene. The patient’s room is well ventilated, it is air conditioned and
spacious. Because the patient is sensitive to light, they use dim light in
the room to protect eye strains that will aggravate more pain to his
condition.

NURSING DIAGNOSIS:

RISK FOR INFECTION r/t immunosuppression / compromised

immune system

IV. Sensory Status

Because the patient is sensitive to light, they use dim light in the
room to protect eye strains that will aggravate more pain to his condition.
The patient has no difficulty identifying odors. The patient is able to
distinguish sweet, sour, salty and bitter taste. Because of chemotherapy,
he manifests unusual sensation like nausea and vomiting. The patient is
able to discriminate sharp, dull, light, and firm touch. He can perceive
roughness from smoothness.

The patient, with his condition, speaks slowly because he tires

easily. The patient speaks using “Tagalog”. He is able to understand
commands, and imitate speeches normally.

The patient is oriented about the time, place, person, understands

verbal and written words. The patient has complaints of irritability because
of the hospital setting and also agitated due to the effects of his treatment
and with his condition.

NURSING DIAGNOSIS:

FATIGUE r/t decreased oxygen level in the blood as manifested by

tiring easily and agitation when doing ADLs secondary to anemia

ALTERED SENSORY PERCEPTION r/t increased sensitivity to

light as manifested by itching and teary eyes when exposed to light
secondary to chemotherapy

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V. Motor Status

The physician ordered for frequent rest periods and ordered to monitor I
and O as well as signs of bleeding. The patient complains that some of his deep
tendon reflexes decreased. Upon assessing deep tendon reflex, results reveals:
grading in the upper and lower extremities are biceps reflex: +1, triceps reflex: +1
and knee jerk reflex: +1 which means the reflexes are hypoactive and other
reflexes in both extremities has a grade of +2 which is normal. He also complains
of joint pain with pain scale of 8/10. The patient was prescribed to take pain
medication (Morphine Sulfate). The patient needs assistance when doing ADLs
because he is weak.

NURSING DIAGNOSIS:

ACTIVITY INTOLERANCE r/t decrease in number of red blood cells as

manifested by weakness and easy fatigability

ACUTE PAIN r/t cancer cells in the bones and compromised immune
system as manifested by joint pain

VI. Nutritional Status

Before the patient was confined, he loves eating foods rich in

preservative. The patient was ordered for small frequent feedings, small portion
of calorie, increase protein, bland and low residue diet. He verbalizes the desire
to comply with the diet and the importance of complying with it.

She also feels nauseated and vomited a few times every after
chemotherapy. The patient only eats because his mother forces him to do so.
Because of the effects of chemotherapy agents and compromised immune
system, the patient has stomatitis. The patient has complete set of teeth with no
gum problems. The patient cannot easily swallow the foods being introduced to
him because of his stomatitis. He eats very little amount of food due to his
stomatitis. He had also loose weight from 56.82kg to 47kg.

NURSING DIAGNOSIS:

IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS

r/t effects of chemotherapy as manifested by nausea, vomiting and inability to
chew foods easily because of sores in the mouth

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 PAIN r/t inflammation of the oral mucosa as manifested by gums
that bleed easily and inability to chew foods properly

VII. Elimination Status

The patient is having diarrhea due to the effects of chemotherapy. The

patient has a specific gravity of 1.012 and slightly turbid colored urine with some
precipitate. There are no artificial orifices used like ileostomy or colostomy. The
patient is also undergoing blood transfusion of packed red blood cell and platelet.

NURSING DIAGNOSIS:

DIARRHEA r/t effects of chemotherapy as evidenced by 3 or more

passage of loose stools every after treatment

RISK FOR FLUID VOLUME DEFICIT r/t 3 or more passage of

loose stools secondary to chemotherapy

VIII. FLUID AND ELECTROLYTE STATUS

The patient has 2000cc fluid intake and 1,200cc 24-hour urine output.
Serum electrolytes reveals: the following results: K= 3.9mmol/L,
Na=136.2mmol/L, Ca= 8.4mmol/L. The patient has PNSS infusion regulated at
KVO. Uric acid level is 8.1mg/dL which also causes joint paint to the patient.

NURSING DIAGNOSIS:

ACUTE PAIN r/t elevated uric acid in the blood as manifested joint pain

IX. Circulatory Status

The patient has weak and irregular pulse with a pulse rate of 85bpm. The
patient has a blood pressure of 80/50mmHg. Upon assessment, the patient’s
capillary refill is about 3-4seconds.

Laboratory results reveals: blood cell count and examination: hct=36%,

hgb= 12%, rbc count=3.8mil/mm3, wbc count= 9,500/mm3, platelet
count=180,000/mm3. Bone marrow test: 26% of myoblasts or leukemic cells
found in the blood.

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 The patient’s skin is pale, slightly cold to touch, with presence of bruises
on some areas of the body, in the upper and lower extremities. The patient
experiences fatigue.

NURSING DIAGNOSIS:

INEFFECTIVE TISSUE PERFUSION r/t inadequate red blood cell

production and low hemoglobin concentration as manifested by fatigue, pale skin
and shortness of breath

RISK FOR BLEEDING

IMPAIRED SKIN INTEGRITY r/t low platelet count as manifested

by bruises on the skin

X. Respiratory Status

The patient has shallow, irregular breathing with 26cpm. The patient
experiences shortness of breath.

NURSING DIAGNOSIS:

IMPAIRED GAS EXCHANGE r/t decrease oxygen level in the blood

as manifested by shortness of breath upon doing ADLs secondary to anemia

XI. Temperature Status

The patient is feverish with a temperature of 37.9C. The room is well

ventilated with a room temperature of 22C.

XII. INTEGUMENTARY STATUS

There are presence of bruises on some areas of the body which makes
the patient hesitant and conscious to look at himself. Because of loss of hair, he
feels that he looks so unattractive. He had also loosed a total weight of 9kg. He
doesn’t want look at himself at the mirror. The patient is being taken cared by his
mother. His mother assists him in taking a bath. Oral hygiene is emphasized to
the patient.

NURSING DIAGNOSIS:

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 BODY IMAGE DISTURBANCE r/t effects of chemotherapy as
manifested by bruises on the skin and loss of hair

LOW SELF-ESTEEM r/t physical changes in the body as

manifested by bruises, loss of hair, weight loss and verbalization of
unattractiveness

XIII. COMFORT AND REST STATUS

The patient has disturbed sleeping pattern because of

chemotherapy. He sometimes can’t sleep at night because of being bothered by
his condition. He’s also scared that he will no longer be awake. He still can’t
accept his current situation. He undergoes chemotherapy and has two days of
rest periods in one week.

NURSING DIAGNOSIS:

SLEEP DISTURBANCE r/t anxiety as evidenced by verbalization of

feelings of fear and in denial of his illness.

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 Chapter IV

Nursing Analysis

Nursing Problems

INEFFECTIVE TISSUE PERFUSION r/t inadequate red blood cell production

as manifested by fatigue, pale skin and shortness of breath

The patient has anemia which is one of the symptom of AML. Related to
anemia is the nursing diagnosis above. There is ineffective tissue perfusion
because there is an inadequate red blood cell production, thus there is a
decrease hemoglobin concentration in the blood. Hemoglobin transports oxygen
to the body. This is a priority because it falls under one of the ABCs which is
circulation. If there is an inadequate oxygen supply in the body, then our
circulation will be compromised. Oxygen is one of the basic need of a human
being according Maslow’s hierarchy of needs.

RISK FOR INFECTION r/t immunosuppression / compromised immune

system

The patient is at risk for infection because he has a high WBC count and
infection is one of the symptoms of AML. The patient’s immune system is
compromised also due to the effects of chemotherapy that’s why he is at risk for
infection. Signs of infection are gum bleeding, fever, cough and colds and others.
This is second priority because we need to avoid infection so that the patient’s
condition will not get worst. And according to Betty Neuman’s Systems model, a
human is an open system where it consists of a basic structure and a central
core surrounded by two concentric rings referred to as lines of resistance. The
lines of resistance, in his model represents internal factors that defend the client
against a stressor and infection is a stressor. Thus, she means that as nurses we
need to do interventions to prevent stressors that will enter a person’s system

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IMPAIRED SKIN INTEGRITY r/t low platelet count as manifested by bruises
on the skin

The patient has bruises on the skin due to low platelet count. Low platelet
is a condition called thrombocytopenia. The patient is bruises easily.

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