CML Output Cp

8/9/2019 CML Output Cp

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Leukemia is a malignant disease (cancer) of the bone marrow and blood.

It is characterized by the uncontrolled accumulation of blood cells. Leukemia is

divided into four categories: myelogenous or lymphocytic, each of which can be

acute or chronic. The terms myelogenous or lymphocytic denote the cell type

involved. There are four major types of leukemia. Leukemia is the general term

used to describe four different disease-types called:

Acute Myelogenous Leukemia (AML)

Acute Lymphocytic Leukemia (ALL)

Chronic Myelogenous Leukemia (CML)

Chronic Lymphocytic Leukemia (CLL)

The terms lymphocytic or lymphoblastic indicate that the cancerous

change takes place in a type of marrow cell that forms lymphocytes. The terms

myelogenous or myeloid indicate that the cell change takes place in a type of

marrow cell that normally goes on to form red cells, some types ofwhite cells,

and platelets. Acute lymphocytic leukemia and acute myelogenous leukemia are

each composed ofblast cells, known as lymphoblasts or myeloblasts. Acuteleukemias progress rapidly without treatment. Chronic leukemias have few or no

blast cells. Chronic lymphocytic leukemia and chronic myelogenous leukemia

usually progress slowly compared to acute leukemias.

In chronic myelogenous leukemia (CML), the leukemia cell that starts the

disease makes blood cells (red cells, white cells and platelets) that function

almost like normal cells. The number of red cells is usually less than normal,

resulting in anemia. CML starts with a change to a single stem cell.CML patients

have what is called the "Philadelphia Chromosome" (Ph chromosome).

Chromosomes are structures in the cells that contain genes. Every cell with a

nucleus has chromosomes. Genes give instructions to the cells. The Ph

chromosome is made when a piece of chromosome 22 breaks off and attaches

1
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to the end of chromosome 9. A piece of chromosome 9 also breaks off and

attaches to the end of chromosome 22.

From 2003-2007, the median age at diagnosis for chronic myeloid

leukemia was 65 years of age. Approximately 2.5% were diagnosed under age20; 7.4% between 20 and 34; 10.1% between 35 and 44; 13.3% between 45 and

54; 15.0% between 55 and 64; 19.0% between 65 and 74; 22.7% between 75

and 84; and 9.9% 85+ years of age. The age-adjusted incidence rate was 1.5 per

100,000 men and women per year. These rates are based on cases diagnosed

in 2003-2007 from 17 SEER geographic areas. (SEER, National Cancer Institute,

2009)

Both children and adults can get CML, but most CML patients are

adults. About 1,458 in the Philippines are expected to be diagnosed with chronic

myelogenous leukemia (CML).

There are three phases of CML:

1. Chronic Phase CML

Most patients are in the chronic phase of the disease when their CML is

diagnosed. In this phase, CML symptoms are milder. White cells can still fight

infection. Once patients in the chronic phase are treated, they can go back to

their usual activities.

2. Accelerated Phase CML

In the accelerated phase, the patient may develop anemia, the number of

white cells may go up or down, or the number of platelets may drop. The number

ofblast cells may increase and the spleen may swell. People with accelerated-

phase CML may feel ill.

3. Blast Crisis Phase CML

Patients with blast crisis phase CML have an increased number of blast

cells in the marrow and blood. The number of red cells and platelets drops.

Patients may have infections or bleeding. They may also feel tired and have

shortness of breath, stomach pain, or bone pain.

2
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People with CML may not have any symptoms at the time of diagnosis.

They may be diagnosed following a medical examination for another condition or

as part of a periodic checkup. CML signs and symptoms tend to develop

gradually. Some signs and symptoms of CML are:

Tiring more easily

Shortness of breath doing usual day-to-day activities

Pale skin color

Enlarged spleen leading to a "dragging" feeling on the upper left side of

the abdomen

Night sweats

An inability to tolerate warm temperatures

Weight loss.

Many of the signs and symptoms for CML are common to other illnesses.

Most people with these signs and symptoms do not have CML.

Objective of the Study

This case study aims to improve the present condition of the patient and

conducted to gain a thorough understanding concerning the case. And to apply

students knowledge on nursing assessment, problem identification, nursing

interventions and evaluation that is related to the disease condition.

This study also aims to improve the skills of a student in clinical area,

interpersonal relationship with the patient and other health care givers and to

gain more confidence. It also aims to help the patient to solve or reduce his

illness. As nursing students, we impart knowledge of what we have learned in

school and practice that acquired learnings to become an effective nurse

someday. One way to improve our skills is to help patients with their health

problems or illness and applying simple interventions.

The specific objectives of this study are at the end of 2 weeks in Sabal hospital,

we will be able to:

1. Establish rapport to our chosen patient for the Care study.

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http://www.leukemia-lymphoma.org/all_page?item_id=464236#signhttp://www.leukemia-lymphoma.org/all_page?item_id=464236#spleenhttp://www.leukemia-lymphoma.org/all_page?item_id=464236#signhttp://www.leukemia-lymphoma.org/all_page?item_id=464236#spleen


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2. Identify and appraises health problem of the patient.

3. Provides nursing services according to health needs of the patient

4. Helps to develop the competency in the members to take care and when

required and to find out remedial measures to solve health problems.

Scope and Limitation of the Study

This study includes the collection of information specific to the patients

health condition primarily about the said case. The study also comprises the

assessment of the physiological and emotional status, adequacy of support

systems, and care given by the family as well as other health care providers.

However, the study is limited by the following:

Days of care only lasted for 2 days of clinical duty

The data gathered based from the clients chart and the

verbalizations of the client and his significant others.

Home visits were not done due to the distance of the clients home

Consultation with the patients attending physician for additional

data about his current condition were not done.

This study focuses on determining the patients main concern or

problems

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Patients Profile

Name: Mr. Piolo

Age: 62 years old

Gender: Male

Civil Status: Widower

Birthday: November 4, 1948

Height: 55

Weight: 58 kg

Nationality: Filipino

Religion: Roman Catholic

Educational Attainment: College Graduate

Occupation: Retired Soldier

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Pension: 7-10,000 per month

Address: 670 Mabini Burgos, Brgy.13 CDOC

Date of admission: June 30, 2010

Time of admission: 3:05 pm

Chief complaint: Pallor and Dyspnea

Attending physician: Dr. Queja

Admitting Diagnosis: Chronic Myelogenous Leukemia

Family and Personal History

Mr. Piolo, Male, Filipino, 62 years old, is a resident of Mabini, Burgos,

Cagayan de Oro City. He has received all vaccinations during his childhood

years. He has a family history of hypertension on both mother and father side.

And he has no known drug and food allergies. He graduated at the University of

Bohol in a Bachelors Degree of Political Science. He worked as a soldier based

here in the Philippines.

At present, Mr. Piolo is a retired soldier and is independent from his

children. He receives his pension of 7,000 to 10,000 per month. He is a widower

of Mrs. Decir, and they had three (3) children. His eldest, Maris, is a nurse in one

of the schools here in Cagayan de Oro. His middle and youngest children,

Charito and Mae, are now in college pursuing their course of choice in one of the

prestigious schools here in Cagayan de Oro.

Mr. Piolo had an accident during his teenage years while driving his

motorcycle. But he was not admitted because he only acquired skin abrasions

from the accident.

History of Present Illness:

3 years prior to admission, Mr. Piolos friend, a doctor, noticed that he

was very pale. The doctor suggested that he should undergo a laboratory exam,

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CBC. After the result is in, it shows that Mr. Piolo has low Hemoglobin,

Hematocrit and RBC count. After the results, the doctor referred Mr. Piolo to Dr.

Queja for further assessment. The patient underwent another examination, which

led to Dr. Quejas diagnosis of leukemia. From the time of referral and up to the

present, Mr. Piolo is undergoing therapy to improve his condition. His laboratory

examination, CBC, is scheduled every month and his blood transfusion therapy is

scheduled every two (2) months and

Last April 2010, the patient was admitted in Sabal hospital for blood

transfusion as one of the management for his condition. Last, June 29,1010; the

patient had a CBC exam at Sabal hospital, the result showed that he had low

Hemoglobin, Hematocrit and RBC, Dr. Queja the prompted to admit the patient

the next day for the need of blood transfusion.

A. Erick Erickson (Psychosocial Theory)

Mr. Piolos age belongs to the adulthood stage of Erik Erikssons theory of stages

of development. The central task that he ought to resolve at this stage is to resolve

generativity versus stagnation. With Mr. Piolos case, he verbalized that drinking and

smoking is very bad in our health. With this, he was able to accept ones own lifes

uniqueness and worth. The patient shows signs of positive resolution because whenever

he was asked to do something he is very eager to cooperate and respond to the questions

given to him. Furthermore, he also said that he was happy to raise his children and watch

them grow with their respective families now. He also verbalized that he is not afraid to

die at this point in his life because according to him, his task of being a father to his

children and a husband to his wife has been done.

B. Jean Piaget (Cognitive Developmental Theory)

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It refers to the manner in which people learn to think, and use language. It

involves a persons intelligence, perceptual ability, and ability to process information.

Cognitive development represents a progression of mental abilities from illogical to

logical thinking, from simple to complex problems solving, and from understanding

concrete ideas to understanding abstract concepts.

As we observed, Mr. Piolo could talk and communicate well able to answers our

questions correctly, he was still able to think logically and he lives with his good moral

standards.

C. Robert Havighurst (Developmental Task)

According to Robert Havighursts Developmental Theory, the client belongs to

the late maturity stage wherein in there is adjustment to decreasing physical strength and

health. Theres an adjustment to retirement and reduced income. Establishing an explicit

affiliation with ones age group is one of the major highlights of this stage. Adopting and

adapting social roles in a flexible way. Establishing satisfactory physical living

arrangements which are all held true to the client. Since he had his retirement, he was

able to adjust to the life he is having now especially with the death of his spouse, and is

even open to the possibilities that might happen, like things beyond our control.

D. Sigmund Freud (Psychosexual Theory)

According to Freuds psychosocial theory, he belongs to the Genital Stage. During this

final stage of psychosexual development, the individual develops a strong sexual interest

in the opposite sex. Where in earlier stages the focus was solely on individual needs and,

interest in the welfare of others grows during this stage. If the other stages have been

completed successfully, the individual should now be well-balanced, warm, and caring.

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And this is true to the client. The client was very warm and caring, as verbalized by her

grand children and daughter. Although he lost already that sexual urge towards the

opposite sex, he was able to fulfill those things during the earlier stage of his married life.

NURSING SYSTEM REVIEW CHARTVital Signs:

Pulse: 76bpm BP: 100/80mmHg Temp: 35.7C RR: 18 Height: 55 Weight: 58kgEENT:

impaired vision blind

Asses eyes, ears, nose

throat for abnormality no problemRESP: dry lips(7/1/10)

asymmetric tachypnea

apnea rales cough barrel chest Non productive drycough(7/1/10)

bradypnea shallow rhonci sputum diminished dyspnea orthopnea labored wheezing body weakness(7/1/10)

pain cyanotic

Asses resp, rate, rhythm, depth, pattern,

breath sounds, comfort no problem pale nailbeds(7/1/10)CARDIO VASCULAR arrhythmia tachycardia numbness

diminished pulses edema fatigue

irregular bradycardia murmur tingling absent pulses pain

Asses heart sounds, rate rhythm, pulse, blood dark scars and few small wounds

pressure, clrc., fluid retention, comfort

no problemGASTRO INTESTINAL TRACT

obese distention mass

dysphagia rigidly pain

Asses abdomen, bowel habits, swallowing,

bowel sounds, comfort no problemGENITO-URINARY and GYNE

pain urine color vaginal bleeding

hermaturia discharge noctoria

Asses urine freq., color, control, odor, comfort/

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Gyne-bleeding, discharge no problem dry skinNEURO

paralysis stuporous unsteady seizures

lethartic comatose vertigo tremors

confused vision grip

Asses motor function, sensation, LOC, strength, IVF #01 PNSS 1L at10gtts/min

Grip, galt, coordination, orientation, speech, IVF #02 PNSS 1L at10gtts/min

no problem

MUSCULOSKELETAL and SKIN BT #02 at 25gtts/min (July01, 2010)

appliance stiffness itching petechiae BT #03 at 25gtts/min (July01, 2010)

hot drainage prosthesis swelling BT #04 at 25gtts/min (July02, 2010)

lesion poor turgor cool deformity

wound rash skin color flushed

atrophy pain ecchymosis diaphoretic moist

Asses mobility, motion. Galt, alignment, joint function

/skin color, texture, turgor, integrity no problem

Nursing Assessment II

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SUBJECTIVE OBJECTIVE

COMMUNICATION:

[ ] hearing loss[x] visual changes[ ] denied

Comments: Wala man,maayo man akongpandungogGagamit ko ugreading glasses,nearsighted mangud ko.

[x] glasses [ ] languages[ ] contact lens [ ] hearing aid [] speech diff.Pupil: R = 3mm L = 3mmReaction: Pupils Equally Round andReactive to Light and Accomodation

OXYGENATION:[ ] dyspnea[x] smoking history[x] cough[ ] sputum[ ] denied

Comments: atongulitawo pakogasigarilyo ko,

walanaman dayonga hangos ko pagdugay2 na baklaykanang ga apasonang ginhawagi ubo lng ko karonkay nag inum kogbugnaw tubig.

Resp. [x] regular [ ] irregularDescribe: the pt. respiration is regularand has an equal lung expansion.R Symmetrical to leftL Symmetrical to right

CIRCULATION:[ ] chest pain[ ] leg pain[x] numbness of[ ] denied

Comments:usahay maminhod

akong mga tudlodili ma straight

extremities

Heart Rhythm [x] regular [ ] irregularAnkle Edema none

Pulse Car. Rad. DP Fem*R 78 76 pulses present inall areaL 78 76 pulses present in

all area

Comments: normal heart rhythmNUTRITION:Diet: Diet astolerated[ ] N [ ] VCharacter[x] recent changein weight, appetite[ ] swallowingdifficulty[ ] denied

Comments: dilina parehasauna akong ganasanahimong 58kg

pagkaun, from72kg

[ ] dentures [x] none

Full Partialincomplete

Upper [ ] [ ] [ x ]Lower [ ] [ ] [ x ]

ELIMINATION:Usual bowelpatternEvery other day

[ ] constipationremedypt. has noremedies

Date of Last BM:June 29, 2010

[ ] diarrheacharacterNo diarrhea

urinary frequency5-8 times a day[ ] urgency[ ] dysuria[ ] hematuria[ ] incontinence[ ] polyuria[x] foly in place[ ] denied

Comments:The patient has noproblems withbowel and urineelimination.

Bowel Sounds10/minnormoactive

AbdominalDistention: noneUrineRusty, aromatic

MGT. OF HEALTH ILLNESS:[ ] alcohol [x] denied(amount, frequency)sauna ulitawo ko ga inum ko, sukad ato

wala na. Kapoy lang ni nasakit kay

atimanun jud. Hasol kay pirmi ra sabalay gapuyuay _

Briefly describe the pt.s ability tofollow treatments (diet, meds, etc.)for chronic health problems (ifpresent).

The patient follows his medications.

Comply on blood transfusion. Thepatient takes all medicines prescribed.

SUBJECTIVE OBJECTIVESKIN INTEGRITY:

[x] dry[x] itching[ ] other[ ] denied

Comments:

katol usahay niakong tiil maoning nay mgapali-pali kay gakatulon nako.

[x] dry [ ]cold [ ]

pale[ ] flushed [ ]warm[ ] moist [ ]cyanotic

rashes, ulcers, decubitus(describe size, location, drainage)scars on both legs, dark in color,different sizes, small wounds

ACTIVITY/ SAFETY:[ ] convulsion[ ] dizziness[ ]limited motion

of joints

Limitation in ability to[ ] ambulate[ ] bathe self[ ] other[x] denied

Comments:ga walkinggani ko or ga

joggingwala man koylimitasyon sapag lihok-lihokbasta dililang ga ubosakong dugo.

[ ] LOC and orientation:Pt is awake, alert and oriented to

time, date, and placeGait: [ ] walker [ ] cane [ ] other

[x] steady [ ] unsteady ______[ ] sensory and motor losses in face

or extremities: no motor losses in

face

[ ] ROM limitations: active movement

of body parts.COMFORT/SLEEP/AWAKE:[ ] pain(location, frequency,remedies)

[ ] nocturia[ ] sleep difficulties[x ] denied

Comments:wala mayproblema,normal lang judbasta edad-

edaran na dilikayo taas angtulog

[ ] facial grimace[ ] guarding[ ] other signs of pain: No pain noted.

COPING:

Occupation: retired soldier

Members of Household: 3

Most Supportive Person: Daughter

Observed non-verbal behavior:smiling, closing eyes, tearfulness,vigilance, hand and arm movements

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Doctors Order with Rationale

Date/ Time Order RationaleJune 30,2010

3:05pm

July 1, 20103pm

July 2, 2010

Admit under my service

TPR q 4, I & O q shift, Vitalsigns q 4

IVF PNSS 1L @ 10gtts/min

Lab attached to CBC

Transfuse 4units PRBCproperly, type and cross-match each unit to run for 4hour with 4 hour interval inbetween each unit

Premeds for every 2unitsPRBC:1. PCM 500mg; tab2. Benadryl 50mg; cap

Watch out for BT reaction

Congestion precaution

Inform me once admitted

PNSS 1L @ 10gtts/min

May go home

Repeat CBC after 1month

Continue Glivek

For proper managementand by request of thepatient since the doctoris specialized in the field

For monitoring patientshealth status

For preparation for bloodtransfusion, it is the onlysolution compatible forBT

Basis in planning for

treatment, indication forBT

To compensate for lowRBC, hemoglobin, andhematocrit count of thepatients CBC examresult

To prevent /treat sideeffects of BT such asitchiness, increasedbody temperature andchilling

To prevent allergicreaction

Client is CML, chronicphase

To allow physician makeplans during admission

Used for flushing in BT

Patient has consumed4units of PRBC, which ishis main purpose to be

admitted To check the current

status of patients bloodcomponents and forexamination

For treatment of thedisease

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Drug Study

Generic Name Imatinib mesylate

Brand Name Glivec

Date Ordered Last morningClassification Protein Tyrosine Kinase Inhibitor, Antineoplastic

Dose/ Frequency/

Route100 mg BID P.O

Mechanism of

Action

A protein-tyrosine kinase inhibitor which potently inhibitsthe breakpoint cluster region-Abelson (Bcr-Abl) tyrosinekinase at the in vitro, cellular, in vivo levels.

Specific Indication

Treatment of adult and pediatric patients with newlydiagnosed chronic myeloid leukemia (CML) as well asthose with CML in blast crisis, accelerated phase, or in

chronic phase after failure of interferon- therapyContraindication

Hypersensitivity to imatinib or to any of theexcipients of Glivec.

Side Effects

Fluid retention

Muscle cramps or pain

Abdominal pain

Vomiting

Diarrhea

Hemorrhage (abnormal bleeding)

Nausea

Fatigue

Rash

Nursing

Precaution

Should be taken with food and a large glass of waterto minimize the risk of GI disturbances.

Use prescription as directed, even if feeling better.

Take this medicine at a similar time of day.

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Generic Name of

the Ordered DrugMultivitamin

Brand Name Centrum, Stresstabs, Conzace, etc.

Date Ordered Maintenance drug

Classification Vitamins and minerals

Dose/ Frequency/

Route500 mg once daily

Mechanism of

Action

That boosts the body's immune system. It protects against

vitamin C deficiency and enhances the body's resistance

to stress, the common cold and some types of infections.

Specific Indication

Treatment and prevention of vitamin C deficiency,

boosting of the body's immune system, resistance to

colds and infections, speeding up of wound healing and

maintenance of healthy teeth, bones and gums.Contraindication Hypersensitivity to any of its components.

Side Effects

Severe allergic reactions (rash; hives; itching; difficultybreathing; tightness in the chest; swelling of the mouth,face, lips, or tongue).

Nursing Precaution May be taken with or without food

Generic Name Paracetamol

Brand Name Biogesic

Date Ordered June 30, 2010

Classification Antipyretic

Dose/ Frequency/

Route500 mg; tab (premeds for every 2 units of PRBC)

Mechanism of

Action

Reduces fever by acting directly on the hypothalamic heat

regulatory center

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Specific Indication For fever

Contraindication Allergy to drug, to impaired hepatic function

Side Effects Headache

Nursing Precaution

Do not exceed recommended dosage

Check temperature before giving the medication

and after giving the medication

Give drug with food

Generic Name Diphenhydramine hydrochloride

Brand Name Benadryl

Date Ordered June 30, 2010

Classification Antihistamine

Dose/ Frequency/

Route

500 mg; cap (premeds for every 2 units of PRBC)

Mechanism of

Action

Competitively blocks the histamine at H receptor sites,

has atropine like antipruritic and sedative effects

Specific Indication Amelioration of allergic reactions to blood

ContraindicationAllergy to any antihistamines, asthmatic attack, stenosing

peptic ulcer

Side EffectsDizziness DrowsinessDry mouth Sedation

Nursing Precaution

Administer with food

Monitor patient response

Avoid excessive dosage

Laboratory Results with Implications

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Diagnostic Exam Results Normal values Significance of the result

CBC

6/29/10White blood cells

Red blood cells

Hemoglobin

Hematocrit

Platelet

MCV

MCH

Differential countNeutophils

Lymphocytes

Monocytes

Eosinophils

4500mm

2.49

7.3

21.9

1,398,000

88.0

29.2

36

39

24

01

5,000-10,000/mm

4.35-5.90 mil/mm

13.7-16.7 g/dl

40.5-49.7vols%

144,000-372,000

79.7-97.0 u

26.1-33.3pg

43.4-76.2%

17.4-46.2%

4.5-10.5%

2-3%

At risk of infection

Indication of anemia

Indication of anemia

Indication of severe anemia

Malignancy

Normal range

Normal range

Decreased probablybecause of bone marrowdisease

Normal range

Increased probably due tohemolytic disorders

Decreased with stress useof medications

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A. Skeletal System

The skeleton has five major functions. These are:

Support - the body is kept inposition by the muscles that

attach to the skeleton.

Protection- the flat bones

protect the internal organs.

Movement - provided by the

joints

Production of Blood - blood

cells are produced in the red

bone marrow in the centre of

some bones, including the

pelvis, ribs, vertebrae and

stenum. The yellow bone

marrow stores fat. The yellow

bone marrow can convert to

red bone marrow if the body

needs additional blood

production.

Storage - Minerals are stored

in the bone, mostly calcium

and phosphorus.

The Spinal Column

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The spinal column is made up of 33 vertebrae, in a 7-12-5-5-4 combination, as

can be seen from the diagram below. Note that the 5 vertebrae in the sacrum

and the 4 vertebrae in the coccyx are fused. Note also that the spine is curved,

and these curves act as shock absorbers.

The spine may become stressed if these curves are altered.

B. Cardiovascular System

Knowing the functions of the cardiovascular system and the parts of the

body that are part of it are critical in understanding the physiology of the human

body. The cardiovascular system is the system that keeps life pumping through

you with its complex pathways of veins, arteries, and capillaries. The heart, blood

vessels, and blood help to transport vital nutrients throughout the body as well as

remove metabolic waste. They help to protect the body and regulate body

temperature.

The cardiovascular system consists of the heart, blood vessels, and blood.

This system has three main functions:

Transport of nutrients, oxygen, and hormones to cells throughout the body

and removal of metabolic wastes (carbon dioxide, nitrogenous wastes,

and heat).

Protection of the body by white blood cells, antibodies, and complement

proteins that circulate in the blood and defend the body against foreign

microbes and toxins. Clotting mechanisms are also present that protect

the body from blood loss after injuries.

Regulation of body temperature, fluid pH, and water content of cells.

Blood Formation

Hemopoiesis (hematoiesis) is

the process that produces the

formed elements of the blood.

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of each kind of white blood cell begins with the division of themopoietic stem cells

into one of the following blast cells.

Myeoblasts divide to form eosinophilic, neutrophilic, or basophilic

myelocytes, which lead to the development of the three kinds of

granulocytes.

Monoblasts lead to the development of monocytes.

Lymphoblasts lead to the development of lymphocytes.

Thrombopoiesis

Thrombopoiesis, the process of making platelets, begins with the

formation of megakaryoblasts from hemopoietic stem cells. The megakaryoblasts

divide without cytokinesis to become megakaryocytes, huge cells with a large,

multilobed nucleus. The megakaryocytes then fragment into segments as the

plasma membrane infolds into the cytoplasm.

C. Lymphatic System

An important supplement to the cardiovascular system in helping to

remove toxins from the body, the lymphatic system is also a crucial support of

the immune system. Unlike blood, lymph only moves one way through your body,

propelled by the action of nearby skeletal muscles. The lymph is pushed into the

bloodstream for elimination. Appreciating the importance of the lymphatic system

in filtering, recycling, and producing blood as well as filtering lymph, collecting

excess fluids, and absorbing fat-soluble materials is important in the

understanding of human physiology.

The lymphatic system consists of lymphatic vessels, a fluid called lymph,

lymph nodes, the thymus, and the spleen . This system supplements and

extends the cardiovascular system in the following ways:

The lymphatic system collects excess fluids and plasma proteins from

surrounding tissues (interstitial fluids) and returns them to the blood

circulation. Because lymphatic capillaries are more porous than blood

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capillaries, they are able to collect fluids, plasma proteins, and blood cells

that have escaped from the blood. Within lymphatic vessels, this collected

material forms a usually colorless fluid called lymph, which is transported

to the neck, where it empties into the circulatory system.

The lymphatic system absorbs lipids and fat-soluble materials from the

digestive tract.

The lymphatic system filters the lymph by destroying pathogens,

inactivating toxins, and removing particulate matter. Lymph nodes, small

bodies interspersed along lymphatic vessels, act as cleaning filters and as

immune response centers that defend against infection.

The movement of lymph through lymphatic vessels is slow (3 liters/day)

compared to blood flow (about 5 liters/minutes). Lymph does not circulate like

blood, but moves in one direction from its collection in tissues to its return in the

blood. There are no lymphatic pumps. Instead, lymph, much like blood in veins,

is propelled forward by the action of the nearby skeletal muscles, the expansion

and contraction of the lungs, and the contraction of the smooth muscle fibers in

the walls of the lymphatic vessels. Valves in the lymphatic vessels prevent the

backward movement of lymph.

Lymphatic Tissues and Organs

Lymphatic cells are organized into tissues and organs based upon how tightly

the lymphatic cells are arranged and whether the tissue is encapsulated by a

layer of connective tissue. Three general categories exist:

Diffuse, unencapsulated bundles of lymphatic cells. This kind of lymphatictissue consists of lymphocytes and macrophages associated with a

reticular fiber network. It occurs in the lamina propria (middle layer) of the

mucus membranes (mucosae) that line the respiratory and gastrointestinal

tracts.

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Discrete, unencapsulated bundles of lymphatic cells, called lymphatic

nodules (follicles) . These bundles have clear boundaries that separate

them from neighboring cells. Nodules occur within the lamina propria of

the mucus membranes that line the gastrointestinal, respiratory,

reproductive, and urinary tracts. They are referred to as mucosa-

associated lymphoid tissue (MALT). The nodules contain lymphocytes and

macrophages that protect against bacteria and other pathogens that may

enter these passages with food, air, or urine. Nodules occur as solitary

nodules, or they cluster as patches or aggregates. Here are the major

clusters of nodules:

o Peyer's patches are clusters of lymphatic nodules that occur in the

mucosa that lines the ileum of the small intestine.

o The tonsils are aggregates of lymphatic nodules that occur in the

mucosa that lines the pharynx (throat). Each of the seven tonsils

that form a ring around the pharynx are named for their specific

region: A single pharyngeal tonsil (adenoid) in the rear wall of the

nasopharynx, two palatine tonsils on each side wall of the oral

cavity at its entrance in the throat, two lingual tonsils at the base of

the tongue, and two small tubal tonsils in the pharynx at the

entrance to the auditory tubes.

o The appendix, a small fingerlike attachment to the beginning of the

large intestine, is lined with aggregates of nodules.

Encapsulated organs contain lymphatic nodules and diffuse lymphatic

cells surrounded by a capsule of dense connective tissue. The three

lymphatic organs are discussed in the following sections.

Lymph nodes

Lymph nodes are small, oval, or bean-shaped bodies that occur along

lymphatic vessels. They are abundant where lymphatic vessels merge to form

trunks, especially in the inguinal (groin), axillary (armpit), and mammary gland

areas. Lymph flows into a node through afferent lymphatic vessels that enter the

convex side of a node. It exits the node at the hilus, the indented region on the

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opposite, concave side of the node, through efferent lymphatic vessels. Efferent

vessels contain valves that restrict lymph to movement in one direction out of the

lymph node. The number of efferent vessels leaving the lymph node is fewer

than the number of afferent vessels entering, slowing the flow of lymph through

the node.

Lymph nodes perform three functions:

They filter the lymph, preventing the spread of microorganisms and toxins

that enter interstitial fluids.

They destroy bacteria, toxins, and particulate matter through the

phagocytic action of macrophages.

They produce antibodies through the activity of B cells.

The structure of a lymph node is characterized by the following features:

A capsule of dense connective tissue surrounds the lymph node.

Trabeculae are projections of the capsule that extend into the node

forming compartments. The trabeculae support reticular fibers that form a

network that supports lymphocytes.

The cortex is the dense, outer region of the node. It contains lymphatic

nodules where B cells and macrophages proliferate.

The medulla is the center of the node. Less dense than the surrounding

cortex, the medulla primarily contains T cells.

Medullary cords are strands of reticular fibers with lymphocytes and

macrophages that extend from the cortex toward the hilus.

Sinuses are passageways through the cortex and medulla through which

lymph moves toward the hilus.

ThymusThe thymus is a bilobed organ located in the upper chest region between

the lungs. It grows during childhood and reaches its maximum size of 40 g at

puberty. It then slowly decreases in size as it is replaced by adipose and areolar

connective tissue. By age 65, it weighs about 6 g.

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Each lobe of the thymus is surrounded by a capsule of connective tissue.

Lobules produced by trabeculae (inward extensions of the capsule) are

characterized by an outer cortex and inner medulla. The following cells are

present:

Lymphocytes consist almost entirely of T cells.

Epithelial-reticular cells resemble reticular cells, but do not form reticular

fibers. Instead, these star-shaped cells form a reticular network by

interlocking their slender cellular processes (extensions). These

processes are held together by desmosomes, cell junctions formed by

protein fibers.

Epithelial-reticular cells produce thymosin and other hormones believed to

promote the maturation of T cells.

Thymic (Hassall's) corpuscles are dense, concentric layers of epithelial-

reticular cells. Their function is unknown.

The function of the thymus is to promote the maturation of T lymphocytes.

Immature T cells migrate through the blood from the red bone marrow to the

thymus. Within the thymus, the immature T cells concentrate in the cortex where

they continue their development. Mature T cells leave the thymus by way of

blood vessels or efferent lymphatic vessels, migrating to other lymphatic tissues

and organs where they become active (immunocompetent) in immune

responses. The thymus does not provide a filtering function similar to lymph

nodes (there are no afferent lymphatic vessels leading into the thymus), and

unlike all other centers of lymphatic tissues, the thymus does not play a direct

role in immune responses.

Blood vessels that permeate the thymus are surrounded by epithelial-reticular

cells. These cells establish a protective blood-thymus barrier that prevents theentrance of antigens from the blood and into the thymus where T cells are

maturing. Thus, an antigen-free environment is maintained for the development

of T cells.

Spleen

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Measuring about 12 cm (5 in) in length, the spleen is the largest lymphatic

organ. It is located on the left side of the body between the diaphragm and

stomach. Like other lymphatic organs, the spleen is surrounded by a capsule

whose extensions into the spleen form trabeculae. The splenic artery, splenic

vein, nerves, and efferent lymphatic vessels pass through the hilus of the spleen

located on its slightly concave, upper surface. There are two distinct areas within

the spleen:

White pulp consists of reticular fibers and lymphocytes in nodules that

resemble the nodules of lymph nodes.

Red pulp consists of venous sinuses filled with blood. Splenic cords

consisting of reticular connective tissue, macrophages, and lymphocytes

form a mesh between the venous sinuses and act as a filter as blood

passes between arterial vessels and the sinuses.

The functions of the spleen include the following:

The spleen filters the blood. Macrophages in the spleen remove bacteria

and other pathogens, cellular debris, and aged blood cells. There are no

afferent lymphatic vessels and, unlike lymph nodes, the spleen does not

filter lymph.

The spleen destroys old red blood cells and recycles their parts. It

removes the iron from heme groups and binds the iron to the storage

protein.

The spleen provides a reservoir of blood. The diffuse nature of the red

pulp retains large quantities of blood, which can be directed to the

circulation when necessary. One third of the blood platelets are stored in

the spleen.

The spleen is active in immune responses. T cells proliferate in the whitepulp before returning to the blood to attack nonself cells when necessary.

B cells proliferate in the white pulp, producing plasma cells and antibodies

that return to the blood to inactivate antigens.

The spleen produces blood cells. Red and white blood cells are produced

in the spleen during fetal development.

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IDEAL NURSING MANAGEMENT

NURSING

DIAGNOSIS

GOALS INTERVENTI

ON

RATIONAL

E

EVALUATION

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Altered Nutrition: Lessthan Body Requirementsr/t decreased Intake and

loss of appetite

Short Term:

At the end of2 hours of NursingIntervention,

client will beable to:

Displayimprovedenergy leveland increasedappetite.

Long Term:

At the end ofat least24hours ofNursingInterventions,client will beable to:-demonstratenutritionalintakeadequate tomeetmetabolicneeds asevidenced byincreased

weight

Independent:

1. Obtain athoroughnutritionalassessment.

2. Provide apleasantatmosphere atmealtime;removenoxious stimuli.

3. Provide oralhygiene beforemeals.

4. Provide thefeedings in theprescribedamount and ontime.

5. Ambulate andincreaseactivity astolerated.

- Identifiesdeficiencies/needs to aid inchoice in

intervention.

- Useful inpromotingappetite.

- A clean mouthenhancesappetite.

-May reducefatigue and thusenhance intakewhile preventinggastricdistention.

- Helpful inexpulsion offlatus.Reduction ofabdominaldistensioncontributes to

overall recoveryand sense ofwell- being anddecreasespossibility ofsecondaryproblems.

After the NursingInterventions, thegoals were partiallymet.

2days after the day of

assessment, thepatient wasdischarged; the groupwas not able toevaluate the longterm goal.

However, before hewas discharged, hehas shown slightincrease in energylevel.

NURSING DIAGNOSIS OBJECTIVES

IMPLEMENTATION EVALUATIONIntervention Rationale

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Knowledge deficittreatment related tounfamiliarity of treatmentand lack of resources

Short-TermAt the

end of 8hours ofNursinginterventions,

the patientand his SOwill be ableto:1. Verbalize

understanding of hisconditionandtreatment.

2. Exhibitincreasedinterest/assumeresponsibility for ownlearningand beginto look forinformationand askquestions

Independent1.Provide

informationrelevant to thesituation.

2.Identifyinformation thatneeds to beremembered.

3.Begin withinformation theclient alreadyknows andmove to whatthe client doesnot know,progressingfrom simple tocomplex.

Dependent1. Identifyavailablecommunityresources andsupport groups(e.g. healthcenter).

1. Providesrelevantknowledge.

2. Establishesthe content tobe included.

3. Facilitateslearning.

1. For continuityof care and topromotewellness.

After the Nursinginterventions, thegoals were partiallymet. The patient andhis SO were able toverbalize

understanding ofcondition andtreatment.

He alsoable to initiatelifestyle changes andparticipate intreatment regimen.

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Actual Nursing Management

S ga hangos ko pag dugay2 na baklay kanang ga apason angginhawa

O

Low RBC, Hgb. Hct

pale

A Ineffective tissue perfusion related to low oxygen carryingcapacity of RBCP At the end of 8hours the client will be able to improveappearance and tissue perfusion

I

Independent:

Moderate High Back Rest

promote lung expansion for proper breathing

Instructed Range of Motion

Instructed Breathing Exercises

It improves tissue circulation

Dependent:

Blood Transfusion

to compensate with the low RBC, hgb, hct count of the patientCBC exam result and to supply enough blood needed in thebody.

Administer Glevek

for Philadelphia chromosome positive (ph +) CML

E At the end 8 hours the patient improved his condition. He is notthat pale, no signs and symptoms of SOB

S No subjective cues

O Low WBC

Weak

Pale

A Risk for Infection related to inadequate secondary defenses (decreaseHgb and decrease WBC)

P At the end of 12 hours, the patient will be able to identify interventions toreduce risk of infection and to understand the risk factors.

I Independent:

Place in a private room. Limit visitors as indicated.

To protect patient from potential sources of pathogens/infection.

Instructed proper handwashing

To prevents cross contamination and reduces risk of infection

Proper hygiene

To protect patient from potential sources of pathogens/infection.

Encourage deep breathing exercises

Monitor skin color, notify pallor

Proliferation of WBC can reduce oxygen carrying capacity of theblood.

E

At the end of 12hours, patient was able to identify interventions to reducerisk of infection and to understand the risk factors. 31


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Medication: The patient was instructed that compliance of taking the

medications would improve his condition and treat it in

the long run. He was instructed to continue taking Glivek

with the right dose, and at the right route. He was

instructed to comply in all the medications being allotted

for him or to maintain taking the drugs that are for

maintenance.

Exercise: During his stay in the hospital, the client was assisted in

doing ROM exercises to promote circulation; He was also

assisted in walking, when he would go to the bathroom.

Avoid strenuous activities to avoid over consumption of

oxygen. He can also perform activities of daily living with

minimal effort.

Treatment The patient was instructed to cooperate in planned

interventions for his condition. Cooperate with doctors

treatment plan such as routine and scheduled blood

transfusion, weekly check-up and monthly CBC exam.

He was also encouraged to ask question about his

condition and the treatment he was undergoing

Out Patient(Check-up)

If discharge, the client was instructed to have a follow-up

check up 1 week after discharge for evaluation of his

condition and his compliance to the home medications

given. He can have routine check-up to the hospital or to

the nearest health care center for his condition to be

monitored and evaluated. He was advised to repeat CBC

after 1 month.Diet Diet as tolerated was advised by the doctor. Patient was

encouraged to take nutritious food rich in Vit.A, Iron and

minerals. For health maintenance and recovery

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He now has decreased physical, physiological and emotional coping mechanism. He is

more prone to infection and complication because of his increasing age. For this reason his body

is not at its optimum functioning which explains the poor prognosis.

Age

He is now at the peak age of his life. At this age, his organ and body function is not the

same before. At this age deteriorating organs are present. Some of it has decreased its function

level. With this info, you could say that his body wont cope up easily with the treatment and

recovery; especially he has a rare disease condition at this age.

Medication and Compliance

Compliance to medication is vital for the prompt improvement of our patients condition.

His medications were being administered per orem. The client received a good prognosis for he

showed willingness to follow or comply with his medication treatment. But medication alone is not

enough for the recovery and treatment. The body should accept the treatment and should

improve his condition, but at his condition; he will be okey for now but later on his blood

components falls down and he will undergo again the same treatment.

Family Support

The patients family showed full emotional, physical, and financial support towards the

patient, thus, he is given a good rating in this criterion. The group observed how well the clients

daughter personally took good care of him and attended to all of his needs during his entire stay

in the hospital. They also provided the patient with all his needs in the ward such as medications,

and other supplies as well.

In one analysis of several clinical studies, three different risk groups were identified

based on a prognostic scoring system that includes several variables: age, spleen size, blast

count, platelet count, eosinophil count and basophil count. In the lowest risk group, the median

survival time was 98 months. In the middle group, the median was 65 months, and in the highest

risk group, the median was about 42 months. Of all patients analyzed, the longest survival time

was 117 months. However, this study pre-dates the advent of treatments using targeted therapy.

A follow-up on patients using imatinib published in the New England Journal of Medicine shows

an overall survival rate of 89% after five years

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Determined recommended dietary plans and provided dietary education

as appropriate. Reinforced to patient the importance of keeping follow-up appointments

with the health care provider.

Explained to the patient the rationale for, side effects of, importance of

taking medications as prescribed.

Informed patient's parents/family/caretaker of pertinent food and drug

interactions.

Implemented measures to the patient's family to improve compliance:

included significant others in all discharge teaching sessions.

Encouraged questions and allowed more time for reinforcement and

clarifications of information provided.

Provided written instructions regarding scheduled appointments with

health care provider, medications prescribed, and signs and symptoms to

report.

Referred to the nearest health center for check-up and monitoring of

condition. But for emergency cases the patient was advised to go to the

nearest hospital for monitoring of condition.

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Prompt medical treatment coupled with quality nursing care; will improved

prognosis of the client diagnosed with chronic myelogenous leukemia

Thorough and accurate physical assessment enabled the students to

identify priority actual and potential problems and provide nursing interventions

appropriate for the clients specific medical condition.

Furthermore, this study provided the students a venue to practice learned

skills and impart valuable health teachings to enhance clients knowledge

regarding her health condition in order to prevent complications and hasten

recovery.

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Besa, E.(Mar 16, 2010) Chronic Myelogenous Leukemia from

http://emedicine.medscape.com/article/199425-overview

Chronic myelogenous leukemia and related disorders: An overview. In: Lichtman

MA, et al. Williams Hematology. 7th ed. New York, N.Y.: McGraw-Hill;

2006.http://www.accessmedicine.com/content.aspx?aID=2148618. Accessed

Sept. 11, 2008.

Cliffs Notes(n.d) The Fastest way to learn. Lymphatic System Components fromhttp://www.cliffsnotes.com/study_guide/Lymphatic-System-Components.topicArticleId-22032,articleId-21980.html#ixzz0tZxAy0PI

Doenges, M., Moorhouse M.F., Murr, A.(2008), Nurses PocketGuide:Diagnoses,PrioritizedInterventions, and Rationales. Philadelphia, Pennsylvania:F.A Davis Company

Integrative medicine and complementary and alternative therapies as part ofblood cancer care. The Leukemia & Lymphoma Society. http://www.leukemia-lymphoma.org/attachments/National/br_1150734030.pdf. Accessed Sept. 17,2008.

Medline Plus(2010) Chronic myelogenous leukemia fromhttp://www.nlm.nih.gov/medlineplus/ency/article/000570.htm

Nowell PC (2007). "Discovery of the Philadelphia chromosome: a personalperspective". Journal of Clinical Investigation : 20332035.

Schull, P.,(2009), Nursing Spectrum Drug Handbook.USA. McGraw-Hill

Smeltzer, S., Bare, B.,(2004), textbook of Medical-Surgical Nursing. Philadelphia.Lippincott Williams & Wilkins

Statistics by country for chronic myeloid leukemia(2010) from

http://www.cureresearch.com/c/chronic_myeloid_leukemia/stats-country.htm

The Leukemia & Lymphoma Society (n.d) Fighting Blood Cancers. ChronicMyelogenous Leukemia. from http://www.leukemia-lymphoma.org/all_page.adp?item_id=8501

Wikipedia(2010) Chronic Myelogenous Leukemia. fromhttp://en.wikipedia.org/wiki/Chronic_myelogenous_leukemia

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http://en.wikipedia.org/wiki/Chronic_myelogenous_leukemia

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