I.

Introduction
I personally selected this case of Acute Myelogenous Leukemia (AML) to
enhance my knowledge concerning its clinical manifestations, possible causes,
cure and prevention, among others. This knowledge will eventually become an
indispensable tool that can be shared to others and will never go out of style. It is
a privilege to embrace this challenge in the form of service to humanity and the
fulfillment of our nursing profession. Our core competence is the bare essential
towards its success.
As a nursing profession, it is imperative to learn new techniques in
modern science in order to develop skills that would benefit the medical world.
This learning potential must be relayed to posterity and develop new techniques,
state -of the- art technology that caters the modern man. In the final analysis, the
achievement of ones endeavor may usher us to find the light we are seeking for.
First of all what is leukemia? Leukemia is a cancer of the blood, and is
characterized by uncontrolled proliferation and accumulation of leukocytes (white
blood cells). Most leukemic cells never mature into functioning leukocytes.
Where in the body is deprived of vital components of its immune system. Also,
the cells accumulate in the blood and in certain organs, forcing out healthy cells
and interfering with the function of that organ. There many different types of
leukemia but the four most important forms are derived from only two types of
cells, lymphocytes and myelocytes. Acute myelogenous leukemia is disorders of
granulocytes. Granulocytes produced by bone marrow, engulf and digest bacteria
and other small particles. This generally appears suddenly with symptoms like
those of cold, and progresses rapidly. The lymph nodes, spleen and liver may

become infiltrated with leukocytes and enlarged. There is often bone pain,
paleness due to anemia, a tendency to bleed easily because of depleted platelets
and high susceptibility to infections. The most common causes of death, which
occurs on the average within three months if without treatment, are hemorrhaging
and uncontrolled infections. Acute myelogenous leukemia occurs much less
frequently in children.

II. Objectives
General Objectives:

After 3 days of giving holistic care, the patient will be able to regain optimum
level of functioning and adopt coping skills in performing activities of daily living.
Specific Objectives:
After 8 hours of giving holistic nursing care, the patient will be able to:
1.
2.
3.
4.

establish rapport with the student nurse

explain reasons of hospitalization
state past medical history related to present condition
identify the precipitating and predisposing factors that can possibly lead to the occurrence

of the condition
5. discuss the management applied upon the occurrence of the disease
After 8 hours of giving holistic care, the student nurse will be able to:
1.
2.
3.
4.
5.
6.
7.
8.

establish rapport with the patient

present the patients personal history
assess the patients level of growth and development
show present profile of functional health patterns
discuss with the patient the different predisposing and precipitating factors
identify the pathophysiology and rationale
construct a comprehensive nursing care plan appropriate for the patient
discuss different measures for home management

PHYSICAL ASSESSMENT
Body Parts

Inspection

Palpation

Percussion

Auscultation

HEAD

Round in shape
Normocepahlic

No tenderness
No Lumps

HAIR

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

SCALP

No dandruff

FACE

Presence of
pimples noted,
No wrinkles,
brown in color

FOREHEAD

Round, brown in
color, No
wrinkles,
pimples noted

No Lumps noted

EYEBROWS

Black in color,
no lesions noted

No Lumps noted

EYELIDS

Closes and opens No Mass noted

without difficulty

EYELASHES

Equally
distributed

CONJUNCTIVA

Pale, moist

SCLERA

Opaque in color,
moist

PUPIL

Pupil equally
round reactive to
light and
accommodation,
Constricts and
dilates

IRIS

Dark brown in
color

No Lumps noted

LACRIMAL

Pale, no
discharges

EXTRAOCULAR Moves without

EYE
any difficulty,
MOVEMENT
follows the six
cardinal gaze
LIPS

Pale in color,
symmetrical

No mass noted

MOUTH

Gums are pale,

fair in size, dry

No mass noted

TONGUE

Pinkish in color,
whitish palate
present

TEETH

Yellowish with a
complete set of
teeth

PALATE

Hard and soft

palate are pale in
color

UVULA

Rises upon
saying ah,
medially located

TONSILS

Pale in color

NOSE

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

EARS

canthus
NECK

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

SKIN

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

EXTREMITIES:
UPPER:

CHEST

Without IV, can

perform limited
ROM exercises,
petechiae was
noted (pin point
like appearance)
Equal chest
expansion
RR: 24 breaths
per minute

Clear breath
sounds

LUNGS

LOWER:

Vibration felt
upon tactile
fermitus
BP: 100/60
mmhg

HEART

ABDOMEN

Carotid pulse: 78
beats per minute,
no lumps noted

Brown in color,
no abdominal
distention
Can perform
limited ROM
exercises,

Bowel sounds: 3
upon
auscultation

presence of
petechiae
(pinpoint like
appearance) on
his both legs

III. Nursing Assessment

1. Personal History
1.1Patients Profile
Name: Mr. Abella, Fernando
Age: 50 years old
Sex: Male
Civil Status: Married
Religion: Roman Catholic
Date of Admission: February 04, 2007
Room No. : 532
Complaints: tonsillitis
Diagnosis: Acute Myelogenous Leukemia
Physician: Dr. Ponce, Susie
1.2Family and individual information, social and health history
Mr. Abella, Fernando, 50 yrs. Old, male, Filipino Roman Catholic, who is
married and has four children, all of which are still schooling. The patient works in a
government office. The patient is always exposed in petroleum products and paints.
Mr. Abella is not hypertensive, diabetic and asthmatic. He is an occasional drinker
and a positive smoker which he consumes one pack per day. Mr. Abella was rushed
in the emergency room of Cebu Doctors University Hospital because he fainted and
was very pale. He also complains of tonsillitis.

1.3. Level of growth and Development

Normal Development at Particular Stage

The patient belongs to the middle adulthood. The middle years, from
40 65, have been called the years of stability and consolidation. For most people,
it is a time when children have grown and moved away or are moving away from
home. Thus, partners generally have more time for and with each other and time to
pursue interests they may have deferred for years.
The middle adulthood, the individual makes lasting contributions
through involvement with others. During this period, personal and career
achievements have often already been experienced. Many middle adults find
particular joy in assisting their children and other young people to become
productive and responsible adults. They may also begin to help aging parents. Using
leisure time in satisfying and creative ways is a challenge that, if met satisfactory,
enables middle adults to prepare for retirement.
Men and women must adjust to inevitable biological changes. As in
adolescence, middle adults use considerable energy to adapt self concept and body
image to physiological realities and changes in physical appearance. High selfesteem, a favorable body image, and a positive attitude toward physiological

changes are fostered when adults engage in physical exercise, balanced diet,
adequate sleep, and good hygiene practices that promote vigorous, healthy bodies.

Physical Changes

A number of changes take place during the middle years. At 40, most
adults can function as they did in their twenties. However during ages 40 65,
many physical changes takes place. Both men and women experience decreasing
hormonal production during the middle years. The menopause refers to the so
called change of life in women, when menstruation ceases. It is said to have
occurred when a woman has not had a menstrual period within a year. The
menopause usually occurs anywhere between ages 40 55. The average is about
47 years. At this time, the ovaries decrease in activity until ovulation ceases.
Psychologically, the menopause can be anxiety- producing time, especially if the
ability to bear children is an integral part of womans self concept. The hair begins
to thin and gray hair appears. Skin turgor and moisture decrease, subcutaneous fat
decreases and wrinkling occur. Fatty tissue is redistributed, resulting in fat deposits
in the abdominal area. Skeletal muscle bulk decreases at about age 60. Thinning of
the intervertebral disk causes a decrease in height of about 1 inch. Calcium loss
from bone tissue is more common among postmenopausal women. Muscle growth
continues in proportion to use. Blood vessels lose elasticity and become thicker.
Visual acuity declines, often by the late forties, especially for near vision

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

decreases, particularly in men. Taste sensations also diminish. Metabolism slows,
resulting in weight gain. Gradual decrease in tone of large intestine may predispose
the individual to constipation. Nephron units are lost during this time, and
glomerular filtration rate decreases. Hormonal changes take place in both men and
women.
Cognitive Changes

The middle- aged adults cognitive and intellectual abilities change

very little. Cognitive processes include the action time, memory, perception,
learning, problem solving, and creativity. Reaction time during the middle years
stays much the same or diminishes during the later part of the middle years.
Memory and problem solving are maintained through middle adulthood. Learning
continuous and cab be enhanced by increased motivation at this time in life.
Middle-aged adults are able to carry out all the strategies described in
Piagets phase of formal operations. The experiences of the professional, social, and
personal life of middle-aged persons will be reflected in their cognitive performance.
Thus, approaches to problem solving and task completion will vary considerably in
middle-aged group. The middle-aged adult can reflect on the past and current
experience and can imagine, anticipate, plan and hope.
Changes in the cognitive function of middle adults are rare except with
illness are trauma. The middle adult can learn new skills and information. Some

middle adults enter educational or vocational programs to prepare themselves for

entering the job market or changing jobs.

Moral Changes
During this stage, rules and laws are valued because they maintain social
order worth preserving. Morality is guided by higher principles of human conduct.
Individuals appreciate the social purposes served by laws. They believe laws should
be derived from a democratic consensus. Individuals search their own conscience
for universal ethical principles. They do not make up their own rules but instead
arrive at abstract principles that all religions or moral authorities might view as
compelling or fair. There is a correlation between higher stages of reasoning and
higher levels of moral behavior.
According to Kohlberg, the adult can move beyond the conventional
level to the post conventional level. Kohlberg believes that extensive experience of
personal moral choice and responsibility is required before people can reach the
post conventional level. Kohlberg found that few of his subjects achieved the
highest level of moral reasoning.

Psychosocial Development

The psychosocial changes in the middle adult may involve expected

events, such as marital separation. This change may result in stress that can affect
the middle adults over all level of health. In the middle adult years, as children
depart from the household, the family enters the post parental family stage. Time
and financial demands on the parents decrease, and the couple faces the task of
redefining their own relationship. According to Eriksons developmental theory, the
primary developmental task of the middle years is to achieve generativity.
Generativity is the willingness to care for and guide others. If middle adults fail to
achieve generativity, Stagnation occurs. This is shown by excessive concern with
themselves or destructive behavior toward their children and community.
Spiritual Changes
As man grows older he becomes more aware of the outside world. Some
conform when they are forced to do so, some are driven by self interests and will do
only what they must do to get what they want in return. They violate Gods law
regularly, sinning more or less everyday with little remorse. Their spiritual senses
are not alert. They are ignorant of God and have no concept of holiness. But as man
grows older, he becomes more conscious of how important people really are. Being
good is now important. He thinks about how other people see him and how they
must feel. He realizes that the world runs according to rules. The desire to please
other drives him and when he fails his first response is to justify himself. This faith is
based on the beliefs of the community.

In adult life many individuals develop a faith that is purely their own
individual faith and can deal with the paradoxes and ironies of human existence. A
final stage of development finds some individuals making a commitment to
universal values, such as love and justice. The focus on the value of experience and
reflection and intellectual development finds a strong parallel in the importance
given to the rule of experience and reflection in spiritual growth.
Sexuality Changes
After the departure of their last child from the home, many couples
recultivate their relationships and find increased marital and sexual satisfaction
during middle age. The onset of menopause and the climacteric can affect the
sexual satisfaction during the middle adult. Other factors influencing sexuality
during this period include work stress, diminished health of one or both partners,
and the use of prescription medications.

Diagnostic Test

Normal Value

Result

Significance

Hemoglobin

14-17.5gm/dL

6.77gm/dL

Hematocrit

14-17.5

19.3

WBC

4.4-11.0

174,000

3%

02%

Decreased:

56%

05%

Decreased:

0.3%

--

2.7%

--

34%

07%

4%

61%

4.5-5.9 10 12/L

1.93 10 12/L

80-96fL

100fL

Band
Segmenter
Basophil
Eosnophil
Lymphocyte
Monocyte
RBC
MCV

27.5-33.2pg

35.1 pg

MCH
33.4-35.5%

MCHC

--

MPV

--

RDW

150,000-

Platelet Count

450,000/cu mm

0.5-1.5%

Reticulocyte

0.00-20.00mm/h

ESR

0.7-1.5mg/dL

Creatinine Serum

3.6-5.0mmol/L

Potassium

11-66uL

ALT

137-145mmol/L

Sodium
2.5-7.5mg/L

35.0%
--27,020/cu mm

Decreased: Anemia
Increased:
Erythrocytosis
Increased: Infection

NORMAL
NORMAL
Decreased: Immuno
deficiency
Increased: Viral
infections
Decreased: Anemia
Increased: Macrocytic
Anemia
Increased: : Macrocytic
Anemia
NORMAL
NORMAL
NORMAL
Decreased: Acute
Leukemia

--2.1 mg/dL
3.0 mmol/L
59 uL
134 mmol/L
11.9 mg/L

NORMAL
NORMAL
Increased: Fever
Decreased: Diarrhea
NORMAL
Decreased: Metabolic
Acidosis
Increased: Gout

Uric Acid

Present Profile of the Functional Health Patterns

3.1 Health Perception Pattern

Before the patient was diagnosed with Acute Myelogenous Leukemia
the patient describes himself as a healthy individual. But as of now, he describes his
condition as very poor due to his present condition. In order for him to keep healthy,
he must eat nutritious foods and must not over fatigue himself. He follows the
doctors order and take the medication as needed. The patient refuses to have
chemotherapy due to financial problems.

3.2 Nutritional Metabolic Pattern

Before the patient was not admitted in the hospital, he likes to eat any
kind of foods. But as of now, the patient does not want to eat and he vomits all the
time. The patient drinks alcohol mostly everyday, he prefers to drink Tanduay and
Emperador. The patient also smokes and can consume one pack per day. The
patient takes vitamin supplements like Revicon and Everet. According to the patient
his weight had decreased from 180 pounds to 110 pounds.

3.3 Elimination Pattern

On the first week of his admission, the patient was having hematuria
and melena. After the following weeks, the patients foley bag catheter was

already removed and the patient was having no problems in urinating and
defecating. The patient defecates once in a day.
3.4 Activity or Exercise Pattern
Before, the patient used to walk from his home to his office, but now even
five steps he feels fatigue and will have a difficulty in breathing. The patient was
advised by the physician not to over fatigue himself and he needs enough sleep and
rest.

3.5 Cognitive or Perceptual Pattern

The patient cannot see from far objects. He wears eyeglasses so that he can
see clearly. The patient can hear well enough. The patient often times complains of
fatigue and feels drowsy all the time. The patient is able to read and write.

3.6 Sleep or rest Pattern

Before the patients hospitalization, he sleeps at 7: 00 pm to 6:00 in
the morning, but now because of his condition he sleeps most of the time. The
patient has no problem in sleeping.

3.7 Self Perception Pattern

The patient is concerned about his illness. He is scared that he will die
and might be far away from his family. According to the patient, he wants to be free

from Leukemia but it is too impossible to happen, it needs some miracles. The
patient describes himself as very religious especially with his condition and he must
need some faith to hold on to whatever circumstances might happen. His condition
made him different because unlike normal people he needs to wear a mask all the
time.

3.8 Role Relationship Pattern

The patient prefers to speak Cebuano. He speaks clearly and fluently
and he is able to express himself freely. The patient lives with his family in Matabang Toledo City.

3.9 Coping or stress Tolerance Pattern

The patient and his wife both make the decision especially when it
comes to health and financial matters. He sometimes seeks help to his mother
when it comes t o problem solving because he is more comfortable in asking for
assistance so that he can express his feelings. The patient is still working but he will
just go to work to punch in and leave.

3.10 Value or belief System

The patient is a Roman Catholic and God is very important to him. For
him, God and his family is his source of strength and meaning. The patient prays
the rosary and attends mass every Sunday. The patient wishes to go to Simala to

pray for his condition. According to the patient, he just accepts what Gods plan
awaits him.

IV. Pathophysiology and Rationale

Anatomy and Physiology

The immune system defends the body from invading organisms that
may cause disease. One part of the immune system uses barriers to protect
the body from foreign substances. These barriers include the skin and the
mucous membranes, which line all body cavities; and protective chemicals,
such as enzymes in saliva and tears that destroy bacteria. Another part of the
immune system uses lymphocytes, specialized white blood cells that respond
to specific types of foreign invaders. B lymphocytes produce proteins called
antibodies, which circulate in the blood and attack specific disease-causing
organisms. T lymphocytes attack invading organisms directly.

COMPONENTS OF THE IMMUNE SYSTEM

Macrophage Engulfing Bacterium

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

are large phagocytes, cells that wander through the body consuming foreign
particles such as dust, asbestos particles, and bacteria. They help protect the body
against infection.

White blood cells are the mainstay of the immune system. Some white blood
cells, known as macrophages, play a function in innate immunity by surrounding,
ingesting, and destroying invading bacteria and other foreign organisms in a
process called phagocytosis (literally, cell eating), which is part of the
inflammatory reaction. Macrophages also play an important role in adaptive
immunity in that they attach to invading antigens and deliver them to be destroyed
by other components of the adaptive immune system.

LYMPHOCYTE

Lymphocytes are specialized white blood cells whose function is to identify

and destroy invading antigens. All lymphocytes begin as stem cells in the bone
marrow, the soft tissue that fills most bone cavities, but they mature in two different
places. Some lymphocytes mature in the bone marrow and are called B
lymphocytes. B lymphocytes, or B cells, make antibodies, which circulate through
the blood and other body fluids, binding to antigens and helping to destroy them in
humoral immune responses. Other lymphocytes, called T lymphocytes, or T cells,
mature in the thymus, a small glandular organ located behind the breastbone. Some

T lymphocytes, called cytotoxic (cell-poisoning) or killer T lymphocytes, generate

cell-mediated immune responses, directly destroying cells that have specific
antigens on their surface that are recognized by the killer T cells. Helper T
lymphocytes, a second kind of T lymphocyte, regulate the immune system by
controlling

the

strength

and

quality

of

all

immune

responses.

Most contact between antigens and lymphocytes occurs in the lymphoid organs
the lymph nodes, spleen, and tonsils, as well as specialized areas of the intestine
and lungs (see Lymphatic System). Mature lymphocytes constantly travel through
the blood to the lymphoid organs and then back to the blood again. This
recirculation ensures that the body is continuously monitored for invading
substances.

BONE MARROW

Bone Marrow, soft, pulpy tissue that fills the cavities of bones, occurring in two forms,
red and yellow. One of the largest tissues in the body, bone marrow accounts for 2 to 5 percent of
an adults weight. Red marrow, present in all bones at birth, serves as the blood manufacturing

center. As an infant matures, most of the red marrow in the shaft of long bones, such as the arm
and leg bones, is gradually replaced by yellow marrow. Yellow marrow is composed primarily of
specialized fat cells.
STRUCTURE
Red marrow consists primarily of a loose, soft network of blood vessels and protein
fibers interspersed with developing blood cells. The blood vessels are termed the vascular
component, and the protein fibers and developing blood cells collectively are referred to as the
stroma, or the extravascular component. The protein fibers crisscross the marrow, forming a
meshwork that supports the developing blood cells clustered in the spaces between the fibers.
Red marrow contains a rich blood supply. Arteries transport blood containing oxygen and
nutrients into the marrow, and veins remove blood containing carbon dioxide and other wastes.
The arteries and veins are connected by capillaries, blood vessels that branch throughout the
marrow. In various places, the capillaries balloon out, forming numerous thin, blood-filled
cavities. These cavities are called sinusoids, and they assist in blood-cell production.
Yellow marrow is so named because it is composed of yellow fat cells interspersed in a
rich mesh of connective tissue that also supports many blood vessels. While not usually actively
involved in blood formation, in an emergency yellow marrow is replaced by blood-forming red
marrow when the body needs more blood
MARROW FUNCTION
Red marrow produces all of the bodys blood cellsred blood cells, white blood cells,
and platelets. Red blood cells in the circulatory system transport oxygen to body tissues and

carbon dioxide away from tissues. White blood cells are critical for fighting bacteria and other
foreign invaders of the body .Platelets are essential for the formation of blood clots to heal
wounds. Within red bone marrow, all blood cells originate from a single type of cell, called a
hematopoietic stem cell. Stimulated by hormones and growth factors, these stem cells divide to
produce immature, or progenitor blood cells. Most of these progenitor cells remain in the stroma
and rapidly undergo a series of cell divisions, producing either red blood cells or white blood
cells. At any one time, the stroma consists largely of progenitor cells in various stages of
development. At the appropriate developmental stage, the fresh, new cells squeeze through the
walls of the capillaries. From there, the cells leave the bone and enter the bodys circulatory
system. Some progenitor cells migrate to the sinusoids, where they produce platelets, which also
travel to the circulatory system via the capillaries. Although stem cells are relatively rareabout
1 in every 10,000 marrow cells is a stem cellthey typically produce the forerunners of an
estimated 2 million red cells per second and 2 billion platelets per day. However, if significant
amounts of blood are lost or other conditions reduce the supply of oxygen to tissues, the kidneys
secrete the hormone erythropoietin. This hormone stimulates stem cells to produce more red
blood cells. To fight off infection, hormones collectively termed colony stimulating growth
factors are released by the immune system. These hormones stimulate the stem cells to produce
more infection-fighting white blood cells. And in severe cases, the body converts yellow marrow
into red marrow to help produce needed blood cells.

PREDISPOSING FACTORS

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

Leukemia Overview
CANCER
Cancer is a process of uncontrolled abnormal cell growth and development. Under
normal circumstances, cells are formed, mature, carry out their intended function, and then die.
New cells are constantly regenerated in the body to replace those cells and to maintain normal
cellular function. Cancer represents the disturbance of this process, which can occur in several
ways.Cells may grow and reproduce in a disorganized and out-of-control fashion. Cells may fail
to develop properly, so they will not function normally. Cells may fail to die normally. One or a
combination of these processes may occur when cells become cancerous.

LEUKEMIA
Leukemia is a cancer of blood-forming cells in the bone marrow. These deranged,
immature cells accumulate in the blood and within organs of the body. They are not able to carry
out the normal functions of blood cells.
Normal blood contains 3 major groups of cells: white blood cells, red blood cells, and platelets.
All 3 types of blood cells develop from one immature cell type, called blood/marrow stem cells,
in a process called hematopoiesis.

These stem cells divide and develop to a more developed, but still immature
precursor, called a blast, which then develops through several more stages,
into a mature blood cell.

This process takes place in the bone marrow, which is the soft spongy
material found in the center of most bones.

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

White blood cells (leukocytes) are part of the immune system and help fight a
variety of infections. They also help in the healing of wounds, cuts, and sores.

Red blood cells (erythrocytes) contain hemoglobin, which carries oxygen to,
and removes carbon dioxide from, the cells throughout the various organs of
the body.

Platelets, along with certain plasma proteins, help plug the holes in blood
vessels and form clots once blood vessels are damaged or cut.

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

The myeloid stem cells, or lineage, develop into red blood cells, platelets, and
certain types of white blood cells (granulocytes or monocytes).

The lymphoid stem cells, or lineage, develop into another type of white blood
cell (lymphocytes).

Either lineage can be affected by leukemia. Leukemias that affect the myeloid
lineage

are

called

myelocytic

(also

myelogenous,

myeloblastic,

or

nonlymphocytic) leukemias. Leukemias that affect the lymphoid lineage are

called lymphocytic (also lymphoblastic or lymphogenous) leukemias.
Each of the 2 major types of leukemia, myelogenous and lymphocytic, include both
acute and chronic forms.

Acute essentially refers to a disorder of rapid onset. In the acute myelocytic

leukemias, the abnormal cells grow rapidly and do not mature. Most of these
immature cells tend to die rapidly. In the acute lymphocytic leukemias,
growth is not as rapid as that of the myelocytic cells. Rather, the cells tend to
accumulate. Common to both types of leukemia is their inability to carry out
the functions of healthy white blood cells. Untreated, death occurs within
weeks or a few months.

In the chronic leukemias, the onset tends to be slow, and the cells generally
mature abnormally and often accumulate in various organs, often over long
intervals. Their ability to fight infections and assist in repairing injured tissues
is impaired. However, unlike the acute forms of leukemia, untreated, these
disorders may persist for many months or, as in the chronic lymphocytic
group, many years. A distinctive feature of the chronic myelocytic type is its
invariable conversion, if untreated, to a more rapidly fulminating acute type,
leading to rapid death.

WHAT HAPPENS IN LEUKEMIA?

When a large number of blasts (leukemic cells) appear in the bone
marrow, several things happen. As the leukemic blast cells accumulate in the
bone marrow, they begin to crowd out the normal blood cells that develop
there. Eventually, they take up so much room that red blood cells, platelets,
and normal white blood cells cannot be produced. When that happens, the
young person develops symptoms indicating that normal blood cells are not
being manufactured in adequate numbers:

If red blood cells are crowded out by leukemic cells, the blood will look thin,
which makes the patient look pale. The young person also may be tired,
because the thin blood cannot carry enough oxygen to the heart, lungs, and
muscles.

If blood platelets are crowded out in the bone marrow, the young person may
have bleeding problems and unusual bruising.

If the normal, mature kind of white cells known as neutrophils are crowded
out by the blasts, there will be no cells to combat bacteria, and infections
may occur.
In some cases, leukemic blasts may spill over from the bone marrow into the
blood, where they can be seen by microscopic examination. This may cause a
rise in the number of white cells in the blood (the white blood cell count). In
other cases, only a few blasts appear in the blood, and the white cell count
does not change much. When leukemic blasts are present in the blood, they
may be carried to other places in the body and enter various body organs.
Sometimes they grow in these organs as well as in the bone marrow.

Cancer cells

ACUTE MYELOGENOUS LEUKEMIA

Normal cells

A PICTURE OF ACUTE MYELOGENOUS LEUKEMIA

Acute myelogenous leukemia (AML) is a cancer of the blood and bone marrow
the spongy tissue inside bones where blood cells are made.

It's called acute leukemia because it progresses rapidly and affects immature blood cells,
rather than mature ones. It's called myelogenous (MI-uh-loj-uh-nus) leukemia because it affects a
group of white blood cells called the myeloid cells, which normally develop into the various
types of mature blood cells, such as red blood cells, white blood cells and platelets. This type of
leukemia is also known as acute myeloid leukemia, acute myeloblastic leukemia, acute
granulocytic leukemia and acute nonlymphocytic leukemia.
Normally, your bone marrow produces immature cells (stem cells) in a controlled way, and they
mature and specialize into the various types of blood cells as needed. In people with acute
myelogenous leukemia, the bone marrow produces immature cells that usually develop into a
type of abnormal white blood cell. These abnormal cells aren't able to mature and perform their
usual functions. Even worse, they multiply rapidly and can crowd out healthy cells, leaving a
person with acute myelogenous leukemia vulnerable to infection, anemia or easy bleeding.
Leukemia cells can also spread outside the blood to other parts of your body.Acute myelogenous
leukemia is the most common form of leukemia. It worsens quickly if not treated, but it initially
responds well to treatment. Unfortunately, many people with acute myelogenous leukemia
experience a relapse. Much research is focused on decreasing the risk of relapse and improving
the long-term outcomes for people with acute myelogenous leukemia
CAUSES

The cause of acute myelogenous leukemia is damage to the DNA of developing cells in
your bone marrow. Under normal circumstances, your DNA is like a set of instructions for your
cells, telling them how and when to grow and divide. Certain genes on your DNA called
oncogenes promote cell division. Other genes, called tumor suppressor genes, slow down cell
division and cause cells to die at the appropriate times.
Acute myelogenous leukemia can occur when damage to DNA turns on oncogenes or turns off
tumor suppressor genes. When this happens, blood cell production goes awry. The bone marrow
produces immature cells that develop into leukemic white blood cells called myeloblasts. These
abnormal cells are unable to function properly, and they can build up and crowd out healthy
cells.The DNA mutations that cause leukemia are usually acquired rather than inherited
but researchers and doctors don't always understand exactly how. In some cases, damage to DNA
is the result of exposure to cancer-causing chemicals, including previous chemotherapy for other
cancers. There's also a chance of AML progressing from other blood diseases and chronic
leukemias, such as chronic myelogenous leukemia, myelodysplasia or other disorders in which
the bone marrow produces too much of certain types of blood cells (myeloproliferative
disorders).

RISK FACTORS
The risk of acute myelogenous leukemia increases with age. It's most prevalent in people in
their 60s and older. The disorder is also more common in males than in females. Other possible
risk factors include:

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

radiation therapy or treatment for childhood acute lymphocytic leukemia
(ALL) may have a greater risk of developing AML.

Exposure to radiation and certain chemicals. People exposed to very

high levels of radiation, such as survivors of an atomic bomb blast or a

nuclear reactor accident, have an increased risk of developing AML. Exposure

to certain chemicals, such as benzene which is found in unleaded gasoline
and used by the chemical industry also is linked to greater risk of AML.

Smoking. AML is linked to cigarette smoke, which contains benzene and

other known cancer-causing chemicals. Smokers older than 60 face twice the
risk of AML that nonsmokers do.

Other blood disorders. People who've had another blood disorder, such as
myelodysplasia, polycythemia vera or thrombocythemia, are at greater risk of
developing AML.

Genetic disorders. Certain genetic disorders, such as Down syndrome, are

associated with an increased risk of AML.

CLASSICAL
SYMPTOMS

Anemia

CLINICAL SYMPTOMS

Manifested

Dyspnea

During the assessment,

Fatigue

the student nurse

Pale skin,
mucous
membrane,
conjunctiva,
nail beds

observed that the

patient has a pale skin,
oral mucosa,
conjunctiva and nail
beds. The patient also
verbalizes that he feels
weak and sometimes he
had difficulty in
breathing even doing
things with no exerted
force.

RATIONALE

More specific signs and

symptoms of acute
myelogenous leukemia
are caused by a lack of
properly functioning
blood cells, resulting
from overcrowding by
leukemia cells. The
oxygen carrying
capacity of hemoglobin
is reduced causing
tissue hypoxia and can
result to fatigue,
weakness and dyspnea
(p. 276 disease
management for nurse
practitioner by: Scilling)
In acute melogenous
leukemia, there is the

Thrombocytopenia

loss of bone marrow

Manifested
The patient had a low
platelet count levels
(27,020cu mm)

function because of the

replacement of the
malignant cells such as
occurs in leukemia,
which results in
decrease production of
platelets
(p. 265 disease
management for nurse
practitioner by: Scilling)
In acute myelogenous
leukemia, bleeding is
evident because of a

decrease circulating

Bleeding
Manifested

platelets or impaired

One week prior to

platelet function.

admission, the patient

Bleeding that results

experiences hematuria

from platelet deficiency

and bloody stools. The

commonly occurs in

patient also has

small vessels and is

petechiae in his

characterized by

surrounding skins.

petechae and purpura

(p. 265 disease
management for nurse

practitioner by: Scilling)

In acute myelogenous
leukemia, the bone
marrow produces
immature cells that
usually develop into a
type of abnormal white
Neutropenia

infection

Manifested

blood cell. These

The patient was advised

abnormal cells aren't

by his physician to wear

able to mature and

mask all the time and

perform their usual

must eat foods that ca

functions. Even worse,

boost his immune

they multiply rapidly

system

and can crowd out

healthy cells, leaving a
person with acute
myelogenous leukemia
vulnerable to infection
(http://www.mayoclinic.c
om)
The symptoms of AML
are caused by low
numbers of healthy

blood cells and high

numbers of leukemia
cells. White blood cells

fever

Manifested

fight infection. Low

The patient had fever

numbers can lead to

one week prior to his

fever and frequent

admission because of

infections. With

massive tonsillitis

immunosuppression the
body the body is often
unable to respond an
infection with a
characteristic indicator,
such as fever
(http://www.marrow.org)
(p. 660 Nursing Care of
acutely ill and
chronically ill patient by:
Lagerquist)

In patient who is
immune-suppressed, the
oral mucous membranes
are often a source of
infection; therefore a

complain of a sore
Manifested

throat is an important of
early indication of a

tonsillitis

The patient complains of

potential problem

having difficulty in
swallowing because of
tonsillitis.

(p. 660 Daviss NCLEXRN Success by:

Lagerquist)
These is because of the
proliferation of leukemia
cells within organs
(p. 897 medical- surgical
nursing by: Brunner)

Not Manifested
Not Manifested
Spleenomegaly
Hyperplasia of the
gums
Bone pain

Not Manifested

Nursing Interventions
1. Care Guide in Patient with disease Condition

TREATMENT
Treatment of patients with acute myelogenous leukemia depends on age and the subtype of
the disease. In general, treatment falls into two phases:

Remission induction therapy. The purpose of the first phase of treatment

is to kill the leukemia cells in your blood and bone marrow. However,
remission induction usually doesn't wipe out all of the leukemia cells, so you
need further treatment to prevent the disease from returning.

Consolidation therapy. Also called post-remission therapy, maintenance

therapy or intensification, this phase of treatment is aimed at destroying the
remaining leukemia cells. It's considered crucial to decreasing the risk of
relapse.

Therapies used in these phases include:

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

common course of therapy involves two chemotherapy drugs cytarabine (Cytosar-U),
followed by an anthracycline drug, such as daunorubicin (Cerubidine) or idarubicin
(Idamycin). A third medication, thioguanine, is sometimes used.
If you have AML, you'll probably stay in the hospital during the treatment cycle because
the chemotherapy destroys many normal blood cells in the process of killing leukemia
cells. This chemotherapy can cause anemia, infection and bleeding. If the first cycle of
treatment doesn't cause remission, you may need it repeated one or two more times.
Other drug combinations also may be used, depending on your specific situation.

Chemotherapy can also be used for consolidation therapy. This phase may include a
combination of different medications that mimic the induction, but usually includes high
doses of cytarabine by itself for one to three cycles. Your doctor may also prescribe
medications that boost white cell production to reduce the risk of infection. These
medications are called granulocyte colony stimulating factors (Neupogen, Leukine).

Other drug therapy. Arsenic trioxide and all-trans retinoic acid (ATRA) are
anti-cancer drugs that can be used alone or in combination with
chemotherapy for remission induction of a certain subtype of AML called
promyelocytic leukemia. These drugs cause leukemia cells with a specific
gene mutation to mature and die, or to stop dividing.

Biological therapy. Also known as immunotherapy, biological therapy uses

substances

that

bolster

your

immune

system's

response

to

cancer.

Monoclonal antibodies are one form of biological therapy. These antibodies

are produced in a laboratory, but they mimic protein products found in your
immune system (antibodies) that attack foreign substances (antigens) on
leukemic cells. Gemtuzumab ozogamicin (Mylotarg) is a monoclonal antibody
linked to a chemical toxin that attaches to AML cells. It's used to treat older
people with AML who don't respond to initial treatment or who relapse after
successful initial treatment. Researchers are testing its effectiveness in
younger people with AML.

Bone marrow transplant. This is another option for consolidation therapy

for people at high risk of relapse or for treating relapse when it occurs. This
procedure allows someone with leukemia to re-establish healthy stem cells by
replacing their leukemic bone marrow with leukemia-free marrow. If you

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

radiation therapy to destroy your leukemia-producing bone marrow. This
marrow is then replaced by bone marrow from a compatible donor (allogeneic
transplant). In some cases, you may also be able to use your own bone
marrow for transplant (autologous transplant). This is possible if you go into
remission and then save healthy bone marrow for a future transplant.

Stem cell transplant. Stem cell transplant is also used for consolidation
therapy. It's similar to bone marrow transplant except the stem cells are
collected from circulating blood (peripheral blood), rather than from the bone
marrow, thanks to a medication that causes larger numbers of stem cells to
be released from the bone marrow. The cells used for transplant can be your
own healthy cells, or they can be collected from a compatible donor. This
procedure is used more frequently than bone marrow transplant because of
shortened recovery times and possible decreased risk of leukemia recurrence.

Radiation Therapy.Radiation therapy involves the use of radiation to kill cancer cells
and shrink tumors. For AML, external radiation therapy is used.In external radiation
therapy radiation is directed at the tumor from a source outside the body. This type of
treatment is used for AML that has spreador may spreadto the brain and spinal cord.
It can also be used to treat bone pain that comes from bone affected by the leukemia.

NCP

s- dali na kayo ko kutasan ug kapuyan na ko dae, mga lima ka lakang kapuyon

na ko as verbalized by the patient

o-

weakness

-feeling of exhaustion
-low RBC counts: 1.93
- low hemoglobin count: 6.77
-shortness of breath
-fatigue
-blood pressure: 100/60 mmhg

A-

Activity Intolerance: fatigue related to anemia

P-

demonstrate a decrease in physiologic signs of intolerance

I-

plan care with rest periods between activities

elevate head of bed as tolerated

provide positive atmosphere, while acknowledging difficulty of the situation of

the patient

provide quiet environment, maintain bed rest as indicated. Limit visitors,

phone calls and reported unplanned interruptions

prioritize nursing care schedules to enhance rest.

use energy techniques such as shower chair, sitting performing task

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

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

weakness, dizziness occur

change patient position slowly and monitor for dizziness

E-

the patient shows a decrease signs of intolerance

s-

ingon si doc dae na pa mason ko niya kai para dili ko ma takdan sa mga

sakit
As verbalized by the patient

o-

increase white blood cells:174,000

presence of immature leukocytes

compromised immunity
wears mask
low eosinophil: 0%
low lymphocyte: 07%

A-

Risk for infection related to proliferation of immature lymphocytes

P-

the client will be free from acquiring infection

I-

maintain a fluid intake of at least 2500 ml per day

use good handwashing technique and encourage patient to do the same

protect client from others with infections

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

instruct patient to wear mask all the time

eliminate fresh salads and unpeeled fresh fruits and vegetables

allow no fresh flowers

administer antimicrobials as needed

E-

the patient shows a decrease signs of intolerance

s-

pait kaau ning akong kahimtang, naa pa koi mga anak nga gagmay sa tanan

ako pa jd wala mn me kwarta As verbalized by the patient

o-

sad facial expression

crying

A- Anticipatory grieving related to possible loss of loved one

P-

will be able to express feelings of anxiety

I-

encourage verbalization of fears, concerns and questions regarding disease

treatment

encourage active participation of patient or family in care and treatment

decisions

be with patient most of the times

encourage verbalization of negative feelings, including anger and hostility

allow periods of crying and expression of sadness

use therapeutic communication skills of active listening, silence,

acknowledgement

advise for professional counseling

permit verbalization of anger with acknowledgement of feelings and setting of

limits regarding destructing behavior

E-

the patient was able to verbalize feelings of anxiety

OBJECTIVES

CONTENTS

METHODOL
OGY

GOAL: After 3 days

of varied teaching and
learning experience,
the patient and
significant others will
be able to gain
knowledge, attitude
and skills about his
disease condition and
how to prevent
fatigue.
After 45 minutes of
student nurse-patient
interaction, the patient
will be able to:
1. identify
predisposing
factors in
acquiring
leukemia

2. enumerate
signs and
symptoms of
leukemia

1. predisposing factors in
acquiring leukemia
1.1 expose to radiation for a
long period
1.2 genetic factors such as
down syndrome
1.3 exposure to chemicals
such as benzene and
drugs that causes aplasic
anemia

Informal
discussion

Informal
2. signs and symptoms of
discussion
leukemia
2.1 fever and infection
related to decrease in
white blood cells
2.2 weakness and fatigue
from anemia
2.3 bleeding tendencies from
decreased platelets

EVALUATION

3. determine the
significance
on wearing a
mask all the
time
4. the patient will
show interest
during the
health
teaching

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

3. significance on wearing
mask all the time
3.1 this is to prevent the
patient from acquiring
any infection
4. shows interest during the
health teaching
4.1 asks questions during the
interaction of the student
nurse
4.2 participates and
encourages the student
nurse to go on to the
discussion
4.3 Shows interest on the
discussion by
cooperating with the
student nurse
5. clustering scheduled
activities
5.1 teach client on how to
cluster activities to
prevent fatigue example:
Monday: 7:00-7:30
(eating breakfast)
7:30 9:00 watching
television for relaxation
9:00-9:30 perform
exercise such as walking
9:30-10:00 reading
books
5.2 let the patient decide
and schedule his planned activities

Informal
discussion

Informal
discussion and
utilization of
pictures

Scheduling
activities and
Informal
discussion

VII. Evaluation and Recommendation:

Early detection of an ailment is vital to the patient.

Oftentimes lack of in-depth

knowledge regarding a condition of a disease may hinder a patient in seeking immediate advice
from medical specialist. Fear and financial problems may sometimes interfere which may often
lead to the severity of the disease.
This I believe is one of the major causes as to why my patient has gone to this terminal
stage of his Acute Myelogenous Leukemia (AML). The nature of his job as a painter exposes
him to great risk of an organ damage. Petroleum products when exposed to a person to a
considerable period of time may often lead a person to this problem. This is also coupled with
lack of knowledge regarding this health hazard.
According to his recent laboratory results, his platelet is 27,000 /cu mm which is very
low compared to the normal platelet count of 150,000-450,000/ cu mm. This shows a decrease in
both platelets and erythrocytes. The patient shows hematuria, melena and petechiae on his both
upper and lower extremities, this is an indication of decrease in platelet as well. Because of lack
of mature and normal granulocytes, the patient had a massive tonsillitis. Since treatment for
chemotherapy is too costly for the patient this could contribute for a compelling severity of his
health condition.
It is necessary to undertake sessions of chemotherapy to prolong the patients life.
Immaturity of leukocytes can also lead to severe infection, the patient is encouraged to wear
mask whenever the condition necessitates. The patient needs proper rest due to fatigue. He also
needs more encouragement from his immediate family member, relatives and friends.

Government sector plays a great role in sustaining financial support for indigent patients.
Health care institutions can also help in the financial assistance of their members. Advancement
of medical technology and profession is always a mileage in the science of medical world.

DTR

VII. Bibliography

Porth, Carolwatson. Pathophysiology.6th edition.

Schilling, Judith A. RN, MSN Disease management for Nurse Practitioners.
Smeltzer, Suzanne. Bare, Brenda. Medical-Surgical Nursing. 10th edition. Lippincott
Wiliams and Wilkins.
Lagerquist, Sally. Nclex-RN Success F.A. Davis Company
Marieb, Elaine. Essentials of Human Anatomy and physiology
education Inc., San Francisco, California. 2003.
Smeltzer. Bare. Medical-Surgical Nursing. 10th edition.
Patrick. Medical-Surgical Nursing. 2nd edition.
Phipps. Long. Woods. Medical-Surgical Nursing

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