Michelle Agte, RN Daniel Villardo Biscocho, RN Alger Vidallon, RN

ACUTE LYMPHOBLASTIC LEUKEMIA

Introduction Causes Risk Factors Symptoms Diagnostic Tests Treatment

ACUTE LYMPHOBLASTIC LEUKEMIA

INTRODUCTION
Acute lymphoblastic leukemia (ALL) is a type of cancer of the blood and bone marrow the spongy tissue inside bones where blood cells are made. The word "acute" in acute lymphocytic leukemia comes from the fact that the disease progresses rapidly and affects immature blood cells, rather than mature ones.

INTRODUCTION
The "lymphoblastic" in acute lymphoblastic leukemia refers to the immature white blood cells called lymphoblast, which ALL affects. Acute lymphoblastic leukemia is also known as acute lymphocytic leukemia and acute childhood leukemia.

INTRODUCTION
WBCs evolve from immature cells referred to as blasts. Malignancy of these blast cells is the source of leukemias, which generally progresses as follows:
Normally, blasts constitute 5% or less of healthy bone marrow. In leukemia, however, these blasts remain immature and multiply continuously, eventually constituting between 30 - 100% of the bone marrow. Eventually these malignant blast cells fill up the bone marrow and prevent production of healthy red cells, platelets, and mature white cells (leukocytes).

INTRODUCTION
They spill out of the marrow into the bloodstream and lymph system and can travel to the brain and spinal cord (the central nervous system). As the number of normal cells decline, dangerous symptoms develop, which, if untreated, become lethal.

INTRODUCTION
Leukemias are divided into two major types:
Acute (which progresses quickly with many immature white cells) Chronic (which progresses more slowly and has more mature white cells)

INTRODUCTION
Acute lymphblastic leukemia is the most common type of cancer in children, and treatments result in a good chance for a cure. ALL can also occur in adults, though the prognosis is not as optimistic.

CAUSES
The causes of the disease are not known, but researchers believe that ALL develops from a combination of:
genetic, biologic, and environmental factors.

RISK FACTORS
Age and Sex Race and ethnicity Heredity disorders Radiation and Chemical Exposure

RISK FACTORS
Age and Sex
ALL is the most common type of cancer diagnosed in children. ALL accounts for about 75% of cases of childhood leukemia. ALL can strike children of all ages, but is most likely to occur when children are 2 - 4 years of age. It is slightly more common in boys than in girls.

RISK FACTORS
Age and Sex Race and ethnicity Heredity disorders Radiation and Chemical Exposure

RISK FACTORS
Race and ethnicity

RISK FACTORS
Race and ethnicity
Caucasian and Hispanic children have a higher risk for ALL than African-American children.

RISK FACTORS
Age and Sex Race and ethnicity Heredity disorders Radiation and Chemical Exposure

RISK FACTORS

Heredity disorders

RISK FACTORS
Heredity disorders
ALL does not appear to run in families. But certain inherited genetic disorders may increase risk. For example, children with Down syndrome have a 20times greater risk of developing ALL than the general population.

RISK FACTORS
Age and Sex Race and ethnicity Heredity disorders Radiation and Chemical Exposure

RISK FACTORS

Radiation and Chemical Exposure

RISK FACTORS
Radiation and Chemical Exposure
Previous cancer treatment with high doses of radiation or chemotherapy can increase the risk for developing ALL. Prenatal exposure to x-rays may also increase risk in children. Lower levels of radiation (living near power lines, video screen emissions, small appliances, cell phones) are unlikely to pose any cancer risk.

SYMPTOMS
Generalized weakness and fatigue Anemia Frequent or unexplained fever and infections Weight loss and/or loss of appetite Excessive and unexplained bruising Bone pain, joint pains Breathlessness Enlarged lymph nodes, liver and/or spleen Petechiae

DIAGNOSTIC TESTS
Blood Sampling Bone Examination Laboratory Tests Imaging Lumbar Puncture

TREATMENT
Chemotherapy Radiation Therapy Blood and Bone Marrow Transplant

Nursing Health History

ALL: A CASE STUDY

Assessment

NURSING HEALTH HISTORY

BIOGRAPHIC DATA
Name: C Age: 12 years old Gender: Male Religion: Roman Catholic Address: San Pedro St., Alaminos, Laguna -------------------------------------------------------------------Date and Time of Admission: November 23, 2010 / 11:14 am Attending Physician: Dr. Castillo Consultant: Dra. Salvador, Hematologist

 CHIEF COMPLAINT:
hematoma and bruises

HISTORY OF PRESENT ILLNESS

5 (Five) days prior to admission, patient manifested hematoma and bruises on both upper and lower extremities associated with gingival bleeding upon brushing of teeth. No consultation done. 3 (Three) days prior to admission, patient developed moderate grade fever associated with decrease of appetite and body weakness. Mother claims that patient has episodes of epistaxis. No consultation done.

HISTORY OF PRESENT ILLNESS

Few hours prior to admission, persistence of above condition, prompt patient to consult at Dr. Castillos Clinic (Pediatrician). Hence, advised for admission at St. Cabrini Medical Center and Cancer Institute under his service.

PAST HISTORY
Patient had previous hospitalization due to Bronchopneumonia (February 2010) and Appendicitis (Appendectomy, August 2010). Patient has no allergies to drug, foods, or other environmental agents.

FAMILY HISTORY
Patient has family history of Anemia and Leukemia on maternal side as claimed by his mother. One of his uncles died with Leukemia.

LIFESTYLE
Nutrition and Metabolism: He eats 3x a day and drinks water approximately 5 glasses a day. During the hospitalization, he was on a diet as tolerated except dark-colored foods regimen. The mother claimed her son has improved his appetite for he was able to consume 80 90% of meal served.

LIFESTYLE
Elimination: During the hospitalization, patients elimination was monitored and recorded. He defecated 3x with normal characteristics of bowel, no hematochezia nor melena noted. He voided spontaneously without experiencing discomfort, no hematuria noted. Activity and Exercise: During the hospitalization, the patient was advised to follow a complete bed rest regimen.

PHYSICAL ASSESSMENT

GENERAL SURVEY (November 26, 2010)

Received patient lying on bed, conscious, responsive, coherent, appeared weak, hematoma and bruises noted on upper and lower extremities and pallor noted. VITAL SIGNS: Temperature: 37.3 Respiratory Rate: 22 Pulse Rate: 84 Blood Pressure: 90/60 mmHg

SKIN
Skin is pale. He has hematoma and bruises on both upper and lower extremities. With no signs of dehydration.

NAILS
Nail plates on fingernails of both hands are slightly pale Capillary Refill Test < 3 seconds.

HEAD AND NECK

Head is normocephalic and symmetrical with frontal, parietal, and occipital prominences. Black hair is evenly distributed with no infestations noted. With eyes slightly protruding. An enlarged left cervical lymph node is palpable, non-tender.

NEUROLOGIC
Alert, oriented to time, place, and person. Coherent and conversant. No complaints of headache nor dizziness noted.

CARDIOVASCULAR
With no extra heart sound noted. With Pulse Rate of 84 bpm, strong and full noted, radial. No palpitations. Blood pressure of 90/ 60 mmHg.

RESPIRATORY
No nasal flaring nor difficulty of breathing noted. No cough and colds as claimed by the patient. With clear breath sounds on both lungs heard upon auscultation. No respiratory depression noted.

GASTROINTESTINAL
Abdomen is soft, flat and non-tender. With gingival bleeding as reported by the mother upon brushing of teeth. No visible blood on stool as reported.

GENITOURINARY
Patient voids spontaneously and reported no discomfort. No flank pain as claimed. No urinary frequency nor urgency as claimed.

MUSCULOSKELETAL
Patient has body weakness but able to move all extremities Able to perform ADLs with assistance.

Enlarged lymph node Pallor Body weakness Hematoma and bruises

Hematoma and bruises

BLOOD AND MARROW

ANATOMY AND PHYSIOLOGY

NORMAL BLOOD AND MARROW

Blood is composed of plasma and cells suspended in plasma. The plasma is largely made up of water in which many chemicals are dissolved. These chemicals include: Proteins (such as albumin) Hormones (such as thyroid hormone) Minerals (such as iron) Vitamins (such as folate) Antibodies, including those we develop from our vaccinations (such as poliovirus antibodies).

NORMAL BLOOD AND MARROW

The cells suspended in plasma include red cells, platelets and white cells (neutrophils, eosinophils, basophils, monocytes and lymphocytes)

NORMAL BLOOD AND MARROW

RED BLOOD CELLS (Erythrocytes)
The red cells are tiny biconcave disks, thin in the middle and thicker around the periphery. The red cells make up half the volume of the blood. They are filled with hemoglobin, the protein that picks up oxygen in the lungs and delivers oxygen to the cells all around the body.

NORMAL BLOOD AND MARROW

PLATELETS (Thrombocytes)
The platelets are small cells (one-tenth the size of red cells) that help stop bleeding at the site of an injury in the body. They become sticky and clump together to form platelet plugs that close breaks and tears in blood vessels.

NORMAL BLOOD AND MARROW

WHITE BLOOD CELLS (Leukocytes)
The white cells serve as bodys defense and immune system.
NEUTROPHILS phagocytize microorganisms and other foreign substances. BASOPHILS release histamine and other chemicals that promote inflammation EOSINOPHILS release chemicals that reduce inflammation and destroys certain parasites.

NORMAL BLOOD AND MARROW

WHITE BLOOD CELLS (Leukocytes)
The white cells serve as bodys defense and immune system.
LYPHOCYTES are responsible for specific immune responses: involve in the production of antibodies, contribute to allergic reactions, rejects grafts, control tumors, and regulate the immune system. MONOCYTES enlarge and become MACROPHAGES which phagocytize bacteria, dead cells, cell fragments, and any other debris within the tissue.

NORMAL BLOOD AND MARROW

BLOOD
Transports gases, nutrients, metabolic wastes, blood cells, immune cells, and hormones throughout the body.

NORMAL BLOOD AND MARROW

MARROW
Marrow is a spongy tissue where blood cell development takes place. It occupies the central cavity of bones. In newborns, all bones have active marrow. By the time a person reaches young adulthood, the bones of the hands, feet, arms and legs no longer have functioning marrow. The spine (vertebrae), hip and shoulder bones, ribs, breastbone and skull contain marrow that makes blood cells in adults.

NORMAL BLOOD AND MARROW

Blood passes through the marrow and picks up formed red and white cells, and platelets, for circulation.

NORMAL BLOOD AND MARROW

The process of blood cell formation is called hematopoiesis. A small group of cells, the stem cells, develops into all the blood cells in the marrow by the process of differentiation

NORMAL BLOOD AND MARROW

Stem Cell

Figure 2. Hematopoeisis. Stem cells give rise to the cell lines that produce the formed elements

NORMAL BLOOD AND MARROW

In summary, blood cells are made in the marrow. When the cells are formed and functional, they leave the Marrow and enter the blood. The red cells and the platelets carry out their respective functions of delivering oxygen and plugging up injured blood vessels throughout the body. The white cells (neutrophils, eosinophils, basophils, monocytes and lymphocytes) enter the tissues to combat infections and perform other immune functions.

ALL: PATHOPHYSIOLOGY

RISK FACTORS 12 years old, Male, Family History

ETIOLOGY unknown

Mutation in the DNA of lymphoid stem cell

Mutation in the DNA of lymphoid stem cell

The cell is prevented from developing beyond the primitive blast stage Leukemia cells persist beyond the life span of normal cells The bone marrow continues to produce leukemia cells incessantly

RISK FACTORS 12 years old, Male, Family History

ETIOLOGY unknown

Mutation in the DNA of lymphoid stem cell

Lymphoblasts remain immature and persist indefinitely

Uncontrolled proliferation of lymphoblasts in the bone marrow

Lymphoblasts replace the normal marrow elements

Decreased production of normal blood cells

Decreased PLATELET

Decreased RBCs

Decreased WBCs

Gingival bleeding

Anemia

Fever

Hematoma
Bruises Epistaxis

Pallor

Decreased production of normal blood cells

RISK FACTORS 12 years old, Male, Family History

ETIOLOGY unknown

Mutation in the DNA of lymphoid stem cell

Lymphoblasts remain immature and persist indefinitely

Uncontrolled proliferation of lymphoblasts in the bone marrow

Lymphoblasts replace the normal marrow elements

Decreased production of normal blood cells

Organ infiltration

Medical Management Nursing Management

WARD COURSE

DAY 1 23 November 2010

MEDICAL MANAGEMENT

MEDICAL MANAGEMENT
DAY 1 November 23, 2010 Dr. Castillo, Attending Physician, ordered patient C for various Laboratory Examinations: CBC, Blood Typing, Peripheral Blood Smear, SGPT, PT, PTT and Urinalysis; and to start Intravenous Fluid of D5NSS incorporated with BNC after negative skin test.

MEDICAL MANAGEMENT
DAY 1 November 23, 2010 Laboratory results were relayed to Dr. Castillo and he ordered for referral to Dra. Salvador, a Hematologist, for hemo consultation and management.

MEDICAL MANAGEMENT
DAY 1 November 23, 2010 8:00 pm, patient was seen and examined by Dra. Salvador reviewing patients history and physical examination with impression of Acute Leukemia, probably Lymphoblastic. Dra. Salvador planned to perform Bone Marrow Aspiration and for Flow Cytometry Leukemia Panel.

MEDICAL MANAGEMENT
DAY 1 November 23, 2010 Dra. Salvador made orders through SMS to prepare 4 units of Platelet Concentrate type specific and transfuse 2 units as fast drip for 2 doses 6 hours apart.

DAY 2 24 November 2010

MEDICAL MANAGEMENT

MEDICAL MANAGEMENT
DAY 2 November 24, 2010 8:00 am, Emla Cream applied on marked area and covered with Tegaderm as ordered as preparation for Bone Marrow Aspiration.

MEDICAL MANAGEMENT
DAY 2 November 24, 2010 11: 00 am, Bone Marrow Aspiration was done at iliac crest by Dra. Salvador. Punctured site pressed for 1-2 hours. Result revealed consistent with Acute Lymphoblastic Leukemia. Medication was started as ordered: Cotrimoxazole 400mg/80cap 1 capsule 2x a day; Vitamin B Complex 5ml 2x a day; Prednisone 20mg/tab 3x a day after meal; Ranitidine 18mg IV every 8 hours.

MEDICAL MANAGEMENT
DAY 2 November 24, 2010 Dra. Salvador also planned patient for possible IT Chemotherapy if platelet count is greater than or equal to 50, 000. For repeat CBC 6 hours post blood transfusion.

MEDICAL MANAGEMENT
DAY 2 November 24, 2010 Patients IVF of D5NSS was shifted to PNSS 500ml x KVO as ordered for Blood Transfusion. Dipenhydramine 18 mg IV was given 30 minutes prior to Blood transfusion as ordered. 10:30 pm, patient received initial transfusion of 2 units of Platelet concentrate and CBC was repeated after 6 hours post BT as ordered. IVF of D5NSS was ordered after Blood Transfusion.

DAY 3 25 November 2010

MEDICAL MANAGEMENT

MEDICAL MANAGEMENT
DAY 3 November 25, 2010 8:00 am, Emla Cream applied on back at L3 and 1 inch above and below, then tegaderm was applied as preparation for IT Chemotherapy. 11:00 am, CSF specimen was sent to Laboratory for CSF cell count and differential count. IT Chemotherapy was done by Dra. Salvador assisted by Nurse-On-Duty.

MEDICAL MANAGEMENT
DAY 3 November 25, 2010 4:00 pm, 2 units of Platelet Concentrate (3rd and 4th) were transfused and CBC was repeated after 6 hours post BT as ordered. 8:45pm, Chemotherapy was started by Dra. Quiatchon (ACOD), as per order of Dra. Salvador, via Slow IV Push assisted by NurseOn-Duty with the following chemodrugs: Vincristine 1mg and Doxorubicin 10mg or 5ml.

DAY 4 26 November 2010

MEDICAL MANAGEMENT

MEDICAL MANAGEMENT
DAY 3 November 25, 2010 Dra. Salvador made orders. Patient for discharge tomorrow with home medication given: Cotrimoxazole, Vitamin B Complex and Prednisone as ordered.

MEDICAL MANAGEMENT
DAY 4 November 26, 2010 6:45 am, patient suddenly experienced epistaxis on both nostrils. Patient was given Hemostan 250mg 1 cap as telephone ordered by Dra. Salavdor and included in home mediction. 9:00 am, 2 units of Platelet Concentrate (5th and 6th) were transfused as ordered.

MEDICAL MANAGEMENT
DAY 4 November 26, 2010 11:00 am, patient complained of epistaxis. Hemostan was given as ordered by Dra. Quiatchon, ACOD May Go Home order was deferred and repeat CBC now was ordered by ACOD due to episodes of epistaxis. 8:30 pm, 2 units of Platelet Concentrate (7th and 8th) were transfused as ordered.

DAY 5 27 November 2010

MEDICAL MANAGEMENT

MEDICAL MANAGEMENT
DAY 5- November 27, 2010 No episodes of bleeding. Hematoma and bruises were less evident. Patient was discharged with improved condition. To come back on November 29, 2010 for Blood Transfusion.

ACTUAL CARE GIVEN

NURSING MANAGEMENT

ACTUAL CARE GIVEN

Nurses on duty were able to get patient history upon admission and throughout confinement. They were also able to assess the patient daily and provided necessary interventions for each needs and problems encountered. They collaborated with the doctors effectively and able to assist on the procedure done. Routine tasks were also provided efficiently.

Infection Protection Bleeding Precautions Energy Conservation

NURSING CARE PLAN

NURSING CARE PLAN

INFECTION PROTECTION

INFECTION PROTECTION
ASSESSMENT (Cues) Enlarged palpable left cervical lymph node noted Axillary temperature of 37.3oC Body weakness noted Post chemotherapy Laboratory Studies: Urinalysis, WBC = 4-8/hpf CBC, Neutrophils: 24 Peripheral Blood Smear, Blast cells = 10 Presence of immature WBCs and decreased normal WBCs.

INFECTION PROTECTION
NURSING DIAGNOSIS Risk for Infection related to inadequate secondary defenses: alterations in mature WBCs.

INFECTION PROTECTION
PLANNING After 8 hours of providing necessary interventions, patient and his family will identify and demonstrate techniques, lifestyle changes to promote safe environment and to prevent or reduce risk of infection.

INFECTION PROTECTION
INTERVENTION Independent Interventions: Place in private room. Limit visitors as indicated. Prohibit use of live plants/cut flowers. Restrict fresh fruits and vegetables or make sure they are washed or peeled. Require good handwashing protocol for all personnel and visitors.

INFECTION PROTECTION
INTERVENTION Independent Interventions: Monitor temperature. Encourage frequent turning and deep breathing. Handle patient gently. Keep linens dry/wrinkle-free. Inspect skin for tender, erythematous areas; open wounds.

INFECTION PROTECTION
INTERVENTION Independent Interventions: Inspect oral mucous membrane. Provide good oral hygiene. Use a soft toothbrush, sponge or swabs for frequent mouth care. Coordinate procedures and tests to allow for uninterrupted rest periods.

INFECTION PROTECTION
INTERVENTION Independent Interventions: Encourage increase intake of foods high in protein and fluids with adequate fiber. Avoid/limit invasive procedures as possible. Provide facial mask.

INFECTION PROTECTION
INTERVENTION Collaborative Interventions: Monitor laboratory studies, e.g.: CBC, noting whether WBC count falls or sudden changes occur in neutrophils; Prepare for/assist with leukemia-specific treatments such as chemotherapy, radiation, and/or bone marrow transplant.

INFECTION PROTECTION
INTERVENTION Collaborative Interventions: Administer medications as indicated, e.g. antibiotics.

INFECTION PROTECTION
EVALUATION Goal met. Patient and his family identified and demonstrated techniques to prevent or reduce risk of infection.

NURSING CARE PLAN

BLEEDING PRECAUTION

BLEEDING PRECAUTIONS
ASSESSMENT (Cues) Episodes of epistaxis noted Pale skin noted with hematoma and bruises evident on both upper and lower extremities Gingival bleeding noted upon brushing of teeth Body weakness noted Laboratory Studies: CBC, Platelet = 50, 000/cumm PT = 15.5 seconds PTT = 44.6 seconds

BLEEDING PRECAUTIONS
NURSING DIAGNOSIS Risk for injury related to bleeding secondary to decreased platelet count.

BLEEDING PRECAUTIONS
PLANNING After 8 hours of nursing interventions, patients risk for injury and bleeding will be minimized.

BLEEDING PRECAUTIONS
INTERVENTION Independent Interventions: Inspect skin/mucous membranes for petechiae, ecchymotic areas; note bleeding gums, frank or occult blood in stools and urine; oozing from invasive-line sites. Implement measures to prevent tissue injury/bleeding e.g., gentle brushing of teeth or gums with soft toothbrush, cotton swab, or sponge-tipped applicator, avoiding forceful nose blowing when possible.

BLEEDING PRECAUTIONS
INTERVENTION Independent Interventions: Provide soft diet. Restrict activity based on assessment on platelet count and presence of active bleeding. Avoid/limit invasive procedures as possible.

BLEEDING PRECAUTIONS
INTERVENTION Independent Interventions: For epistaxis, place patient in high Fowlers position; apply ice pack to back of neck and direct pressure to nose. Notify physician for prolonged bleeding.

BLEEDING PRECAUTIONS
INTERVENTION Collaborative Interventions: Monitor laboratory studies, e.g., platelets, Hb/Hct, clotting. Administer Platelets, Clotting factors. Administer medications as indicated.

BLEEDING PRECAUTIONS
EVALUATION Goal met. Patients risk for injury and further bleeding was minimized.

NURSING CARE PLAN

ENERGY CONSERVATION

ENERGY CONSERVATION
ASSESSMENT (Cues) Body weakness Pale skin noted with hematoma and bruises on both upper and lower extremities. On bed rest regimen Laboratories: Decreased RBC, Hemoglobin, Hematocrit and platelets

ENERGY CONSERVATION
NURSING DIAGNOSIS Activity Intolerance related to therapeutic restrictions (isolation/bed rest)

ENERGY CONSERVATION
PLANNING After 8 hours of nursing interventions, patient will maintain therapeutic regimen as advised to conserve energy and participate in ADLs to level of ability

ENERGY CONSERVATION
INTERVENTION Independent Interventions: Evaluate reports of fatigue, noting ability to participate in activities of ADLs. Provide quiet environment and uninterrupted rest periods. Encourage rest periods before meals.

ENERGY CONSERVATION
INTERVENTION Independent Interventions: Implement energy-saving techniques, e.g., sitting, rather than standing. Assist with ambulation/other activities as indicated. Recommend small, nutritious, high-protein meals and snacks throughout the day.

ENERGY CONSERVATION
INTERVENTION Collaborative Interventions: Provide supplemental oxygen as needed.

ENERGY CONSERVATION
EVALUATION Goal met. Patient maintained therapeutic regimen as advised and participated in ADLs to level of ability. No complaints of fatigue noted.

DISCHARGE PLAN

DISCHARGE PLAN
MEDICATIONS Encourage mother and patient to comply with the medication prescribed by the physician.
Cotrimoxazole Prednisone Vitamin B Comlpex Hemostan

DISCHARGE PLAN
ENVIRONMENT Encourage mother to provide clean environment which is free from infectious agents and to allow patient to rest with a clean surrounding. TREATMENT Instruct the mother to follow the physicians order for patients treatment.

DISCHARGE PLAN
HEALTH TEACHING Discuss health teachings to the mother and patient and allow them to ask questions for further information. OUTPATIENT FOLLOW-UP Encourage frequent resting period and advise on scheduled follow-up.

DISCHARGE PLAN
DIET Instruct the mother to follow the patients diet ordered by the physician. Diet that includes rich in vitamin C , plant sources that are rich in protein and fiber. SPIRITUAL Encourage mother and patient to strengthen their faith and be able to cope with patients condition.

THANK YOU

LABORATORY STUDIES AND DIAGNOSTICS

November 23, 2010 COMPLETE BLOOD COUNT RESULTS NORMAL VALUES 11.2 mg/dl M: 14 17 mg/dl 0.35 % 4.19 million/cumm 50,000/cumm 36, 100/cumm 18 82 0 0 M: 0.42 0.51 % 4 5 million/cumm 150,000 450, 000/cumm 5,000 10,000/cumm 55 65 25 35 24 25

Hemoglobin
Hematocrit Red Blood Cells Platelet Count White Blood Cells Segmenters Lymphocytes Eosinophils Monocytes

Basophils

0 0.5

November 25, 2010 COMPLETE BLOOD COUNT RESULTS 10.2 mg/dl 0.33 % 3.85 million/cumm 66,000/cumm 49, 100/cumm 24 75 01 0

Hemoglobin Hematocrit Red Blood Cells Platelet Count White Blood Cells Cells Segmenters Lymphocytes Eosinophils Monocytes

NORMAL VALUES M: 14 17 mg/dl M: 0.42 0.51 % 4 5 million/cumm 150,000 450, 000/cumm 5,000 10,000/cumm 55 65 25 35 24 25

Basophils

0 0.5

November 26, 2010 COMPLETE BLOOD COUNT RESULTS 10.1 mg/dl 0.31 % 3.81 million/cumm 80,000/cumm 15, 300/cumm 38 60 2 0 0

Hemoglobin Hematocrit Red Blood Cells Platelet Count White Blood Cells Cells Segmenters Lymphocytes Eosinophils Monocytes Basophils

NORMAL VALUES M: 14 17 mg/dl M: 0.42 0.51 % 4 5 million/cumm 150,000 450, 000/cumm 5,000 10,000/cumm 55 65 25 35 24 25 0 0.5

November 23, 2010

BLOOD TYPING Blood Typing Rh Positive Blood Typing ABO Type B

November 23, 2010

PERIPHERAL BLOOD SMEAR Red cells are generally HYPOCHROMIC and MICROCYTIC. White cells are predominantly lymphocytes. There are no toxic granules. There are blast cells seen. Platelets are few. Segmenters 23 Lymphocytes 62 Monocytes 5 Blast 10 Actual Platelet Count 50s REMARKS: Consider Acute Leukemia Further hema evaluation needed.

November 23, 2010

SGPT/ALT

SGPT Result 32

Normal Value (M) < 41 U/L

November 23, 2010

PT and PTT Blood Test RESULT Prothrombin Time 15 seconds 44.6 seconds Partial Thromboplastin Time
or defective factor VIII, IX, or XI.

NORMAL 12 16 seconds seconds 24 39 seconds A prolonged PTT means that clotting is taking longer to occur than expected and may be seconds due to a variety of causes. Normal PT and slightly prolonged PTT may indicate decreased

November 23, 2010

URINALYSIS Color Yellow Transparency Slightly Cloudy Specific Gravity 1.010 pH 6.5 Albumin Negative Sugar Negative WBC 4 8/hpf RBC 0 2 /hpf Bacteria Few EpiCells Occasional Mucusthreads Moderate AmorphSed Moderate Trichomonas None Crystals None Casts None

BONE MARROW ASPIRATION

Bone marrow aspiration removes a small amount of bone marrow fluid and cells through a needle put into a bone. The bone marrow fluid and cells are checked for problems with any of the blood cells made in the bone marrow. Cells can be checked for chromosome problems. Cultures can also be done to look for infection.

FLOW CYTOMETRY LEUKEMIA PANEL

Flow cytometry identifies types of leukemia cells found in samples of blood, based on the chemicals found on the surface of the leukemia cell. Flow cytometry uses laser beams to identify these different chemicals. Flow cytometry is important in classifying acute lymphocytic leukemia (ALL).

November 25, 2010

BODY FLUID ANALYSIS Specimen: CSF RBC WBC Segmenters Lymphocytes RARE 5 x 106 0 100 %

DRUG STUDY

BNC (Benutrex C)

EMLA CREAM
TOPICAL ANESTHESIC ACTION: numbs the skin and surrounding area INDICATION: indicated as topical anesthetic for minor procedure SIDE EFFECTS: paleness, itching, rash CONTRAINDICATION: contraindicated in patients with a known history of sensitivity to local anesthetics NURSING CONSIDERATION:
Do not apply near eyes or on open wounds. Application to larger areas or for longer times than those recommended could result in sufficient absorption of lidocaine and prilocaine resulting in serious adverse effects

COTRIMOXAZOLE
ANTIBACTERIAL (prohylactic) ACTION: inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid. INDICATION: UTI, URTI, All immunocompromised patients should be treated with cotrimoxazole to prevent Pneumocystis carinii SIDE EFFECT: gastrointestinal upset CONTRAINDICATION: Documented hypersensitivity; megaloblastic anemia due to folate deficiency

COTRIMOXAZOLE
NURSING CONSIDERATION:
Skin test Tell patient to take drug as prescribed if he feels better. Tell patient to report adverse reaction. Advise patient to avoid prolonged sun exposure. Take drug on an empty stomach.

VITAMIN B COMLEX
MULTIVITAMINS ACTION:A coenzyme that stimulate metabolic function and is needed for cell replication, hematopoiesis. INDICATION: Anemia SIDE EFFECTS: transient diarrhea CONTRAINDICATION: Documented hypersensitivity

PREDNISONE
CORTICOSTEROID ACTION: Decreases inflammation, mainly stabilizing leukocyte, lysosomal membranes. Suppresses immune system, stimulate bone marrow and influences CHO, CHON, fats INDICATION: Important chemotherapeutic agent in treatment of ALL. SIDE EFFECTS: hypertension, dyslipidemia, hyperglycemia

PREDNISONE
CONTRAINDICATION: Documented hypersensitivity; serious infections (excluding meningitis and septic shock) and fungal infections; varicella infections NURSING CONSIDERATION:
Avoid exposure to infection. Do not stop taking the drug without consultin health care provider

RANITIDINE
H2 - BLOCKER ACTION: reduce stomach acid production INDICATION: to prevent gastric ulcer SIDE EFFECTS: nausea, dizziness, constipation CONTRAINDICATION: hypersensitivity to the drug NURSING CONSIDERATION:
Report sore throat, fever, unusual bruising or bleeding, tarry stools, confusion, hallucinations, dizziness, severe headache, muscle or joint pain.

DIPENHYDRAMINE
ANTIHISTAMINE ACTION: prevents types of transfusion reaction INDICATION: allergic reaction, prophylaxis prior to BT SIDE EFFECTS: sedation, tiredness, sleepiness, dizziness CONTRAINDICATION: hypersensitivity

VINCRISTINE SULFATE
ANTINEOPLASTIC (Chemotherapy Drug) ACTION: interferes with the growth of the cancer cells and slows their growth and spread in the body. INDICATION: Acute Leukemia and other neoplastic conditions SIDE EFFECTS: nausea and vomiting, headache, mouth sores, dizziness, temporary hair loss CONTRAINDICATIONS:Patients with the demyelinating form of Charcot-Marie-Tooth syndrome

VINCRISTINE SULFATE
NURSING CONSIDERATION:
Fatal if given intrathecally. Properly position the intravenous needle/catheter before administering medication. Burning precaution. Tell health care professional immediately if experience pain, irritation, redness, or swelling at the injection site. Must be given slowly into vein only.

DOXORUBICIN
ANTINEOPLASTIC(Chemotherapy Drug) ACTION: interferes with the growth of the cancer cells and slows their growth and spread in the body. INDICATION: Acute Leukemia and other neoplastic condition SIDE EFFECTS: Nausea, vomiting, diarrhea, loss of appetite, CONTRAINDiCATION: baseline neutrophil count <1500 cells/mm3; sever hepatic impairment

DOXORUBICIN
NURSING CONSIDERATION:
Must be given slowly into vein only. Notify doctor immediately if redness, blistering, sores, pain, or swelling occur at/near the injection site.

HEMOSTAN
Antihemorrhagic/antithrombolytic

Intrathecal Chemotherapy Chemotherapy

TREATMENT

INTRATHECAL CHEMOTHERAPY

INTRATHECAL CHEMOTHERAPY
Cancer cells can pass into the cerebrospinal fluid, which surrounds the brain and spinal cord to protect and cushion it. Chemotherapy given by any other route cannot cross over into the cerebrospinal fluid. Therefore the best way to remove these cells is to give chemotherapy directly into the cerebrospinal fluid. The procedure to give intrathecal chemotherapy is called a lumbar puncture (LP).

CHEMOTHERAPY
In chemotherapy, anticancer drugs that damage the DNA in the blood cells are introduced into the bloodstream. Chemotherapy may also be given as palliative treatment, to relieve symptoms without the expectation of a cure, to improve a patient's quality of life. Chemotherapy may also be used as a conditioning therapy prior to a blood and bone marrow transplant.