DW is a 74 year old patient who prior to this diagnosis was in good health , current HX of HTN

with previous HX of Cholecystectomy 5 years ago, carpal tunnel surgery 3 years ago and cataract
surgery in past year. No HX of smoking, occasional social alcohol use noted. Family HX of CA with
patients mother being TX for both lung and bowel CA , mother lived until she was 92 years of age. PT
was definitively DX with AML (acute myelogenous leukemia) on October 15 2009 via results of bone
marrow aspiration report; testing was done in response to PT attempting to get pain injection for back
pain (unspecified source) Dr wanted an MRI done prior to TX, did not like the way the bones appeared
(per patient) on MRI scan and ordered additional blood work, upon results preliminary DX was made
and PT was referred to primary care physician for further evaluation. This admit on October 28, 2009 is
for induction treatment of Chemotherapy, patient was under my care during the second 24 hours of his
admit, on day one the patient had a PICC (peripheral inserted central venous catheter) inserted in his
upper right arm to serve as a route for administration of his chemotherapy treatment. During induction
he was being treated with 2 chemotherapy agents; Idarubicin (idamycin) 12mg/m2/QD given as 24mg
slow injection over 15 minutes QD and Cytarabine 195mg in 1000 NS administered at 41.75ml per
hour for 24 hours. As this was very early in the induction phase he was asymptomatic from both the
chemotherapy and the disease process itself. Physical exam was unremarkable with no complaints of
pain or nausea noted.
Leukemia is a form of cancer characterized by the uncontrolled production of immature white
blood cells in the bone marrow. This process results in the replacement of healthy normal blood cells
by the immature nonfunctional WBC's, due to the rapid proliferation of these cells production of
normal cells is greatly decreased. Classification of Leukemia is done according the cell type that is
proliferating. AML presents as neoplastic growth of cells from the myeloid, monocytic, erythrocytic or
megakaryotic precursors. Etiology of the disease is defined as aberrations in both genetic and
chromosomal markers. Acute myelogenous leukemia is the most common form of adult leukemia;
exact cause is unknown, even with aggressive treatment average survival time is only approximately
one year after diagnosis.
AML is treated in 2 separate phases versus the 3 phases used for ALL; these stages are
induction with cytarabine and an anthracycline (antibiotic based drugs that block DNA synthesis in
neoplasms) and then post remission – intensification, maintenance chemotherapy or bone marrow
transplantation. The goal of this approach to therapy is to achieve a rapid, complete resolution of all
manifestations of the disease. Prophylactic use of antibacterial, antiviral and anti fungal agents is
common to prevent complications from secondary infections related to the suppression/decrease
function of the immune system.
 Leukemia Risk Factors
Textbook (Iggy, pg 898) Patient reported
Exposure to ionizing radiation; either previous N/A
cancer tx or environmental
Previous exposure to chemicals and drugs used in N/A
cancer treatment
Bone marrow hypoplasia N/A
Genetic factors associated with down syndrome, N/A
Bloom syndrome, Klinefelter syndrome or
Fanconi's anemia
Interaction of multiple host and environmental N/A
factors (nonspecific)

Signs and Symptoms

Textbook (Iggy, pg 898) Patient reported
Easy bruising or bleeding (r/t low platelet count) N/A
Paleness/fatigue N/A
Recurrent minor infections N/A
Slow/poor healing of minor cuts abrasions N/A

Diagnosis/Treatment
Patient diagnosis was done per textbook standard, bone marrow aspiration testing is the
definitive test done for confirmation of a Leukemia diagnosis; his initial referral for bloodwork was not
standard as it stemmed from an attempt to get an injection for back pain. Patient treatment at this point
appears to be following the standard regimen used for AML, my patient is currently undergoing
induction phase and it is assumed that this will then be followed up with the post-remission phase of
chemotherapy treatment.
 Medications

Medication Reference page # Action Reason used

Dexamethasone 20mg + 331 Nursing Spectrum Synthetic corticosteroid Prophylactic use to
50 ML NS Drug Handbook works as an anti- offset irritation caused
(N.S.D.H.) inflammatory agent by chemotherapy agents
Idarubicin 23 mg 570 (N.S.D.H.) Inhibits DNA/RNA Causes cell death of
(Idamycin PFS) synthesis of tumor neoplastic cells
(antineoplastic)
Lansoprazole 30mg 637 (N.S.D.H.) Inhibits proton pump in Prophylactic use to
(Prevacid) parietal cells, reducing decrease chance of ulcer
gastric acid production formation/esophagitis –
common s/e of
chemotherapy
Metoclopramide 10mg 746 (N.S.D.H.) Blocks dopamine Prevent chemotherapy
(Reglan) receptors in the CNS induced vomiting
CTZ zone
Multivitamin with Supplements dietary Use is prophylactic to
minerals intake, without intake of supplement dietary
additonal food requirements
NS 1000 ml + 297 (N.S.D.H.) Unclear, cytotoxic effect Causes cell death of
cytarabine 195mg may stem from neoplastic cells
inhibition of DNA by (antineoplastic)
drug's active metabolite
Nifedipine 90mg 822 (N.S.D.H) Calcium channel Hx htn, suppresses
(Procardia XL) blocker smooth and vascular
muscle contraction
 10/29/2009 Diagnostics Value Nrml Significance
WBC 42.2 4 - 11 Proliferation of WBC is
at this point unchecked
by the chemotherapy
RBC 2.68 3.7 – 5.4 Decrease in RBC due to
overproduction of WBC
due to AML
HGB 8.9 11.4 – 15.4 Decrease in HGB can
occur with chronic
illness due to disease
process itself or
nutritional deficiencies
from disease or
treatment
Hct 27.7 35 - 47 Decrease in HCB can
occur with chronic
illness due to disease
process itself or
nutritional deficiencies
from disease or
treatment
Plt 41 150 - 400 Suppressed from disease
process and side effect
of cytotoxic
chemotherapy drug
regimen
Glucose 140 70 - 110 Elevated from stress
reaction to
environmental change
and administration of
dexamethasone adjunct

Bone marrow aspiration report on October 15th, 2009.

Definitive DX of Acute Myelogenous Leukemia with leukocytosis; severe macrocytic anemia and
moderate/severe thrombocytopenia.
Nursing Diagnosis #2
Fatigue r/t to chemotherapy treatment and decreased tissue oxygenation AEB decreased RBC 2.68 (3.7-
5.4 nrml), HGB 8.9 (11.4 – 15.4 nrml) and HCT 27.7 (35 – 47 nrml).

Goal
Patient will not exhibit or verbalize additional feelings/signs of fatigue while in my care.

Interventions Rationales
Provide adequate nutrition to the patient and Adequate balanced intake is key to maintaining
monitor how much is consumed. If inadequate energy and meeting metabolic needs. Supplement
consider either nutritional supplement or possible is a good concentrated source of nutrition. Dietary
refer to dietary for consult consult would be to offer alternative nutritional
sources or delivery forms.
Ensure adequate fluid intake via oral and monitor Dehydration /fluid imbalance exacerbate increase
IV flow as ordered; decreases risk of dehydration of fatigue and lethargy
and altered fluid imbalance
Encourage adequate rest. Proper amount of rest conserves energy and
decreases feelings of fatigue.
Give metoclopramide (Reglan) 10mg IVP, as Nausea decreases desire to eat, vomiting puts
needed to decrease nausea/vomiting patient at greater risk for dehydration.
Give multivitamin with minerals as prescribed Dietary supplement to address any deficiencies
that are not covered by dietary intake.

Evaluation:
Patient ate 100% of breakfast x2, and 100% of lunch. Fresh water was offered and consumed x 2. NS
ran at 100ml per hour along with NS + cytarabine at 41.54ml per hour. Patient walked floor circuit
three loops, took shower, and was up in chair visiting family during my care. Patient showed no sign of
fatigue and reported no signs of fatigue, compared to previous day.
Nursing Diagnosis #1
Risk for infection r/t environment, impaired WBC function, PICC placement, s.e of TX for disease
process, pt is on Neutropenic precaution though not showing lab values to indicate Neutropenia at this
time.

Goal
Patient will not exhibit Si/Sx of infection (increased temperature, chills, flushed skin) while in my care.

Interventions Rationales
Observe and report signs of infection. Particularly Increased body temperature is often the first sign
at PICC and IV sites. Monitor VS Q4h, monitor of infection. Access sites are at an increase risk of
temperature in particular. infection as the skin integrity is compromised.
Keep room free of fresh fruits, flowers, These raw food types can serve as a carrier for
vegetables, food garnish, nuts pseudomonas, puts neutropenic patient at risk of
infection.
Use strict hand washing protocol any time before This is the easiest way to break the chain of
and after patient contact. Also use of gloves when infection and reduce the rate of nosocomial
indicated. infections.
Note and report any abnormal lab values. Careful attention needs to be placed on a patient
who is undergoing chemotherapy and who is also
under neutropenic precautions.
Aseptic technique when accessing the PICC line Chloroprep scrub for 30 seconds with 30 second
for medication administration. dry time on PICC port prior to use kills any
bacteria that is resident on the surface and
decreases chance of septicemia.

Evaluation:
Patient was afebrile while under my care, temperature of 98.5 at 0800 and 98.6 at 1200. No complaints
of chills, PICC dressing remained CDI (unable to assess under dressing, scheduled for change after my
shift by IV team). Universal hand washing precautions were followed during the shift, also instructed
family regarding use of hand sanitizer in room as well. When up in hall patient also wore a mask for
additional protection.
Nursing Diagnosis #3
Risk for impaired oral mucosa r/t side effects of chemotherapy regimen

Goal
Patient will not exhibit Si/Sx of stomatitis, an inflammation of the oral mucous membranes that is a
side effect of chemotherapy/

Interventions Rationales
Inspect the oral cavity per shift at minimum Assess for any changes in baseline, discolorations,
bleeding or discolorations, could be signs of
stomatitis
Promote use of soft bristle toothbrush and to avoid Soft bristle toothbrush and soft deliberate
brushing too hard brushing will help maintain the integrity of the
oral mucosa.
Encourage the patient to brush his tongue with the Can increase taste sensation, and decrease
toothbrush when doing oral care. bacterial count in oral cavity.
Encourage frequent oral fluid intake. Water is Maintaining moisture in mouth can decrease
preferred incidence of stomatitis
Encourage care in selection of foods that are High salt leads to drying of oral cavity, chips can
eaten, avoid high salt foods (chips), softer foods abrade skin and alter integrity.
that are easier to chew preferred

Evaluation:
Oral cavity was inspected and no problems found. No lesions, bleeding, discoloration noted. Soft
toothbrush was used, frequent water intake and swish was done. Foods were soft and easily chewed.
What I learned from this patient:

I really enjoyed taking care of DW on my first clinical day. We bonded well and I was able to
establish a strong rapport in fairly short order. Pt is a 74 yo male in excellent physical health, outside of
the current disease process his only other medical complaint is hypertension. He seemed to be handling
his current diagnosis in stride, he was not particularly happy with how long he was going to be
hospitalized for treatment but was optimistic regarding the outcome of the treatment, at this point he
seems to be coping very well, as is his wife and daughter.
I learned that I need to become more systematic in my acquisition of information from the
computerized chart, much harder to scan the “chart” and catch abnormal values, etc. I am hoping that
will come with time on the system. I suppose the biggest thing I learned from my patient is how
important it is have a positive attitude and I know from my personal experience what an impact that can
have on the treatment outcome. I would like to check in on him during his hospitalization to see how he
is doing as the treatment progresses if that would be appropriate.
 References
Ignatavicius, D.D., Workman, M.L. (2006) Medical -Surgical Nursing: Critical thinking for
collaborative care. St Louis, MO: Elsevier Saunders.
Schilling, J.A., (2007) Lippincott manual of nursing practice series: Pathophysiology. Philadelphia,
PA: Lippincot Williams & Wilkins
Schull, P.D., (2010) Nursing spectrum drug handbook. New York, NY: McGraw-Hill.