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Chapter I

THE PROBLEM AND ITS SCOPE

               This chapter presents the rationale of the study, scope and

limitations, significance of the study, nursing theoretical background,

review of related literature and flow of the study.

RATIONALE OF THE STUDY

The researcher is a level IV nursing student, have been assigned

in the Medical Ward for the school year 2009 – 2010 chose these study

among the many cases in the area primarily because the researcher is

the primary caregiver of the patient and find the case a new and

interesting topic to learn. It is also a great learning opportunity for the

researcher who has just encountered Leukemia specifically the Acute

Myelocytic Leukemia.

With that, the researcher aim to gain all possible knowledge

about Acute Myelocytic Leukemia. Most importantly, aside from

learning the medical interventions with the client’s case and all

possible surgeries that facilitate treatment, the researcher also aim to

know the nursing care management of patients affected with this

condition. Endowed with such knowledge, the researcher aim to

provide a holistic and the best quality nursing care to patients with the

aforementioned disease. Furthermore, the case is Acute Myelocytic

Leukemia therefore; there is still chance of recovery depending on how

it is being treated and how the pt. responds to initial treatments. This

study is a descriptive in-depth analysis of a client who is afflicted with

Acute Myelocytic Leukemia. This aims to give a clear, scientific and

analytic view of the condition and how it came to be through analyzing

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thoroughly and comprehensively all the gathered relevant data and

relate them both to client and his existing conditions.

SCOPE AND LIMITATIONS

The study was conducted at Perpetual Succour Hospital, 2B,

Room 236. The patient was diagnosed with Acute Myelocytic

Leukemia. There was only one respondent. Also included was his

significant others but only limited. The researcher has only three days

monitoring and rendering service to the patient.

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SIGNIFICANCE OF THE STUDY

           

    The effect of this Critical Analysis Report is envisioned to be

beneficial to the following entities: community, readers and to the one

who make this study.

To the community: This study will enable them to know the important

information about leukemia especially Acute Myelocytic Leukemia or

express their problems and difficulties encountered in dealing with this

kind of illness.

To the Readers: The study will provide them information regarding with

Acute Myelocytic Leukemia. This will help them to be aware that this

kind of illness is life-threathening.

To the one who make this study: This study has given to develop self-

confidence in approaching and dealing with patient diagnosed with

Acute Myelocytic Leukemia. And also to analyze the primary

responsibilities and roles of the nurse as part of the entire health care

team and contain an effective and efficient health care management

concerning the care of a sick child.

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NURSING THEORETICAL BACKGROUND

This study is based on the theory of Faye Glenn Abdellah- 21 Nursing

Problems.

Faye Glenn Abdellah – Twenty-One Nursing Problems

Although Abdellah spoke of the patient-centered approaches, she

wrote of nurses identifying and solving specific problems. This

identification and classification of problems was called the typology of

21 nursing problems.

Adbellah and her colleagues thought the typology would provide a method to

evaluate a student’s experiences and also a method to evaluate a nurse’s competency

based on outcome measures.” (Tomey & Alligood, Nursing theorists and their work 4th

ed., p. 115.

Typology of 21 nursing problems

1.  To facilitate the maintenance of a supply of oxygen to all body

cells

2.  To facilitate the maintenance of nutrition  of all body cells

3.  To facilitate the maintenance of fluid and electrolyte balance

4.  To facilitate the maintenance of elimination

5.  To maintain good body mechanics and prevent and correct

deformities

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6.  To promote optimal activity: exercise , rest  and sleep

7.  To facilitate the maintenance of regulatory mechanisms and

functions

8.  To maintain good hygiene and physical comfort

9.  To promote safety through the prevention of accidents, injury,

or other trauma and through the prevention of the spread of

infection

10. To facilitate the maintenance of sensory function

11.To facilitate the maintenance of effective verbal and non verbal

communication

12. To promote the development of  productive interpersonal

relationships

13. To facilitate progress toward achievement of personal spiritual

goals

14.   To accept the optimum possible goals in the light of

limitations, physical and emotional

15.   To recognize the physiological responses of the body to

disease conditions

16.   To identify and accept positive and negative expressions,

feelings, and reactions

17.   To identify and accept the interrelatedness of emotions and

organic illness

18.   To create and / or maintain a therapeutic environment

19.   To facilitate awareness of self as an individual with varying

physical, emotional, and developmental needs

20.   To use community resources as an aid in resolving problems

arising from illness

21.   To understand the role of social problems as influencing

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factors in the case of illness

REVIEW OF RELATED LITERATURE

Leukemia is a malignant disease of the blood-forming organs.

The American Cancer Society estimated that in 2003 about 30,600 new

cases of leukemia would be diagnosed , and about 21,900 deaths

would be attributed to the disease. Leukemia is the most common

malignancy in children and young adults. Half of all leukemias are

classified as acute, with rapid onset and progression of disease

resulting in 100% mortality within days to months without appropriate

therapy. The remaining leukemias, classified as chronic, have a more

indolent course. In children 80% are lymphocytic and 20% are

nonlymphocytic. In adults the percentages are reversed, with 80% no

lymphocytic (Black and Hawks, 2005).

Acute myelocytic (myeloid, myelogenous, myeloblastic,

myelomonocytic) leukemia is a life-threatening disease in which the

cells that normally develop into neutrophils, basophils, eosinophils, and

monocytes become cancerous and rapidly replace normal cells in the

bone marrow (Freireich, 2008).

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Acute leukemia is believed to begin in a single somatic

hematopoietic progenitor that transforms to a cell incapable of normal

differentiation. Acute myeloid leukemia is a very heterogeneous

disease from a molecular standpoint; oncogenic transformation into a

leukemic stem cell may occur at different stages of normal

hematopoietic cellular maturation, from the most primitive

hematopoietic stem cell to later stages, including myeloid/monocytoid

progenitor cells and promyelocytes. This determines which subtype of

acute myeloid leukemia results, often with very different behavior and

growth characteristics (Weinblatt, 2009).

Acute myeloid leukemia (AML) is one of the most common types

of leukemia among adults. This type of cancer is rare under age 40. It

generally occurs around age 65. AML is more common in men than

women. Persons with this type of cancer have abnormal cells inside

their bone marrow. The cells grow very fast, and replace healthy blood

cells. The bone marrow, which helps the body fight infections,

eventually stops working correctly. Persons with AML become more

prone to infections and have an increased risk for bleeding as the

numbers of healthy blood cells decrease (American Cancer Society,

2007).

Most of the time, a doctor cannot tell you what caused AML. However,

the following things are thought to lead to some types of leukemia,

including AML:

Certain chemicals (for example, benzene)

Certain chemotherapy drugs, including etoposide and drugs

known as alkylating agents

Radiation

Problems with your genes may also play a role in the development of

AML.

You have an increased risk for AML if you have or had any of the

following:

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A weakened immune system (immunosuppression) due to an

organ transplant

Blood disorders, including:

o Polycythemia vera

o Essential thrombocythemia

o Myelodysplasia (refractory anemia)

Exposure to radiation and chemicals

Mortality/Morbidity

In 2007, an estimated 8990 deaths from acute myelogenous

leukemia (AML) occurred in the United States. Of these, 5020

occurred in men and 3970 occurred in women.

In adults, treatment results are generally analyzed separately for

younger (18-60 y) and older (>60 y) patients with acute

myelogenous leukemia (AML).

o With current standard chemotherapy regimens,

approximately 30-35% of adults younger than 60 years

survive longer than 5 years and are considered cured.

o Results in older patients are more disappointing, with

fewer than 10% of surviving over the long term. (Seiter,

2009).

Childhood acute myeloid leukemia (AML) is a cancer of the blood-

forming tissue, primarily the bone marrow . AML is also called acute

nonlymphocytic leukemia or acute myelogenous leukemia. There are

several subtypes of AML. It is less common than acute lymphocytic

leukemia (also called acute lymphoblastic leukemia or ALL), another

leukemia that occurs in children and adolescents. Children with Down

Syndrome have an increased risk of developing acute myeloid

leukemia during the first three years of life (National Institutes of

Health, National Cancer Institute, Children's Oncology Group, 2005).

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Flow of the Study

Input

Throughput/Process

Output

A case of 2 year

old, male patient

diagnosed with

Acute Myelocytic

Leukemia.

He complained of

persistent on and

off fever, and

cough thus

prompted his

admission.

He has no known

heredo-familial

disease.

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Figure 1

Schematic Diagram

DEFINITION OF

MEDICAL/ NURSING

TERMS

Anatomy – is a

branch of

biology and

medicine that is

the

consideration of

the structure of

living things

Physiology – is

the study of the

mechanical,

physical and

biochemical

functions of living organisms

Pathophysiology – is the study of the changes of normal

mechanical, physical and biochemical functions, either caused by

a disease, or resulting from an abnormal syndrome

Gordon’s Functional Health Pattern – is a method devised by

Marjory Gordon to be used by nurses in the nursing process to

provide a more comprehensive nursing assessment of the

patient

Management

Medical

Management

Pharmacological

Treatment

Recommendations:

The patient/S.O is

advised to always

maintain a clean

environment, limit

visitors, and do ROM

exercises and

assistance in

performance of

patient’s activities of

daily living.

Prognosis:

Good- if treated

immediately with

chemotherapy and

medical mgt.

Poor- if untreated

immediately, it would

lead to sepsis then

eventually death.

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Physical Assessment – the part of the health assessment

representing a synthesis of the information obtained in a

physical examination. It involves the detailed examination of the

body from head to toe using the techniques of

observation/inspection, palpation, percussion and auscultation.

Accumulation- increase or growth by addition especially when

continuous or repeated <accumulation of interest>.

Acetaminophen- A drug that reduces pain and fever (but not inflammation). It

belongs to the family of drugs called analgesics.

Acute leukemia- A rapidly progressing cancer that starts in blood-

forming tissue such as the bone marrow, and causes large numbers of

white blood cells to be produced and enter the blood stream.

Acute myeloid leukemia- An aggressive (fast-growing)

disease in which too many myeloblasts (immature white blood

cells that are not lymphoblasts) are found in the bone marrow

and blood. Also called acute myeloblastic leukemia, acute

myelogenous leukemia, acute nonlymphocytic leukemia, AML,

and ANLL.

Blood- A tissue with red blood cells, white blood cells,

platelets, and other substances suspended in fluid called

plasma. Blood takes oxygen and nutrients to the tissues, and

carries away waste.

Bone marrow- The soft, sponge-like tissue in the center of

most bones. It produces white blood cells, red blood cells, and

platelets.

Bone marrow infiltration- Anemia characterized by

appearance of immature myeloid and nucleated erythrocytes

in the peripheral blood, resulting from infiltration of the bone

marrow by foreign or abnormal tissue.

Metastasis- The process by which cancer spreads from the

place at which it first arose as a primary tumor to distant

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locations in the body.

Hemostasis- The stoppage of bleeding or hemorrhage. Also,

the stoppage of blood flow through a blood vessel or organ of

the body.

Susceptability- is our inherited and aquired predispositions to

illness, whether it be physical, mental/emotional or both.

Neutropenia- is a condition in which the number of

neutrophils in the bloodstream is decreased.

thrombocytopenia - a blood disease characterized by an

abnormally small number of platelets in the blood.

Anemia- is a condition that develops when your blood lacks

enough healthy red blood cells.

Liver - It converts food into substances needed for life and

growth, storing glycogen (a blood-sugar regulator), amino

acids, protein, and fat. It also makes the enzymes and bile that

help to digest food.

Spleen- a large, highly vascular lymphoid organ, lying in the

human body to the left of the stomach below the diaphragm,

serving to store blood, disintegrate old blood cells, filter

foreign substances from the blood, and produce lymphocytes.

Erythrocyte- A cell that contains hemoglobin and can carry

oxygen to the body. Also called a red blood cell (RBC).

Hepatomegaly- is swelling of the liver beyond its normal size.

Spleenomegaly- Enlargement of spleen.

Lymph node- Also sometimes referred to as lymph glands,

lymph nodes are small rounded or bean-shaped masses of

lymphatic tissue surrounded by a capsule of connective tissue.

Lymph nodes are located in many places in the lymphatic

system throughout the body. Lymph nodes filter the lymphatic

fluid and store special cells that can trap cancer cells or

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bacteria that are traveling through the body in the lymph fluid.

Lymphadenopathy- Abnormally enlarged lymph nodes.

Commonly called "swollen glands."

CHAPTER II

PRESENTATION, ANALYSIS AND INTERPRETATIONS OF DATA

Client profile

Patient JA, 2 years and 9 months old male Filipino, Roman

Catholic, was born on September 21, 2006 and from Babag 1, Lahug,

Cebu City.

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Past Medical History

When the client is only 4 months old, sought consultation at

Baranggay Health Unit together with his mother because of convulsion

and productive cough (color: whitish-green Texture: sticky). His

previous hospitalization was on May 9, 2009, patient was admitted at

Visayas Community Hospital with complaints of cough and fever.

Persistence of symptoms; was referred and readmitted at Perpetual

Succour Hospital last May 29, 2009 for blood dyscrasia. Confined at

PSH-2B room 236, and was diagnosed of having Acute Myelocytic

Leukemia last June 2, 2009 by Dr. Maglana.

History of Present Illness

1 day PTA at around 4am, pt. experienced an onset of fever

38.9ºC per axilla, given calpol prn, for fever with temporary

temperature relief asssociated with productive cough. Persistence of

on and off fever, thus pt sought admission at PSH.

Environmental History

The patients mother description of their place was “ kinababwan

sa bukid amo dai, ubos sa tower”, peaceful, having a good relationship

with the nearest neighborhood. Their means of lightning is lamp and

their means of fire is charcoal, there is only one window , one room,

their water resources is from nature which they called “tubod”, they

have no domestic animal , their toileting is a matter of open-pit privy

or sometimes, went to neighborhood to pee. Their drainage system is

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an open-drainage and their garbage disposal is either buried or

burned. They make used of available source of medication which was

some herbal medicine such as “ gabon , bayabas, atis, malungay,

ampalaya , tuba-tuba, oregano and mangagaw” . They also make used

of some immediate over the counter drugs such as “calpol or

paracetamol biogesic for kids” only if there is free sample given by the

barangay. As stated by his mother.

Developmental History

The patient is physically fit. He is a healthy child since he was

born. But when the time came that he has this kind of illness, he losses

wt. (from 15.5kg to 12kg.) and become weak. His father stated that

early as 1yr old he had his toilet-training already. Before sleeping, he

urinates first to avoid urinating in the bed. And his father stated that

James loves to play outdoor games like basketball together with his

kuya and friends.

GORDON’S FUNCTIONAL HEALTH PATTERN

1. Health Perception Health Management

Patient’s mother perceived her son to be a very active and

healthy baby (4 months after delivery), she rates it 9/10 despite of the

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occurrence of some disease such as cough and fever. A month prior to

admission, parient’s mother perceived her son to be unhealthy, weak

and rates her son 6/10(10 as the highest and 1 as the lowest), it got

easily ill. Patient’s mother perceived her son to be very sickly and

rated it 5/10. His parents doesn’t know much of his illness and

verbalizes that “ambot nikalit raman gud ni siya, luya siya tan.awn

permente og manluspad.”

Everytime their son get sick they make used of available source

of medication which was some herbal medicine such as “gabon ,

bayabas, atis, malungay, ampalaya , tuba-tuba and mangagaw” . They

also make used of some immediate over the counter drugs such as

“calpol or paracetamol biogesic for kids” only if there is free sample

given by the baranggay, as stated by his mother. They seldomly went

to their Baranggay health center because of insufficient facilities,

unavailable drugs and Physician. They maintain a simple living in their

barrio and sought help to their nearby neighborhood and run through

“faith-healer/quack doctor” easily.

2. Nutritional Metabolic

Last 24 hours prior to admission, patient ate ¼ cup of rice,a bite

of chicken meat and 2tablespoon of vegetable soup. Before

hospitalization, patient's mother regularly prepares his breakfast meal

consisting of ½ glass of milk (bear brand), 1 cup of rice, 2 hot dogs, 1

cup of noodles and a half glass of water. During lunch, his mother

regularly prepares ½ cup of rice,i small plate of “pancit” ,a ½ slice of

fish meat and 1/2cup of water/juice. During dinner time, ½ cup of

rice,1 hardboiled egg, small meat of chicken and ½ cup of water.

Intervals of each meal, comprise of 1biscuit / 1 regular size of bread

with ½ glass of carbonated drink/juice/water.

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During the occurrence of his illness, patient ate: ½ cup of rice

with 4 tablespoon of vegetable soup on it, ¼ serving of vegetable dish,

a bite of hot dog and ½ cup of milk, as his breakfast. Lunchtime meal

comprise of; ½ cup of rice ,vegetable dish, sliced of fish and a ¼ cup of

juice/milk. Dinnertime meal comprise of; ½ cup of rice, a bite of fish

meat with vegetable on it, ½ cup of juice and a sip of water. Each meal

interval,comprise of: a bite of bread (depending on patients appetite to

eat and wish to eat) a sip of water or milk, as his snack. But this

seldomly happen according to patient's mother. The patient doesn’t

have any vitamins due to financial problems. He doesn’t have any

allergies (foods, meds.). The patient is weighing 12kg. Differential of

15.5kg.

3. Elimination

Before the onset of disease, patients voids at a regular rate of 6-

10x/day, aromatic, amber in color amounting of 1/8-1/4 glass

level/void. He defecates 1-2x/day, brown in color, soft in consistency,

pungent odor.

During the onset of disease, patient voids 5-6x/day, amber in

color amounting 1/8glass level/void. He defecates every other day. He

doesn't taking any laxatives or suppositories. Before, he sweats around

¼ glass/day, today, he sweats seldomly according to his mother. The

patient doesn’t use any diaper for him to voids and defecates. He used

the toilet with assistance.

4. Activity Exercise

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Before the onset of disease, according to his mother, the patient

is fond of playing with his older brother “pusil2x”, “Tagu2x”, “Bala2x”

and “dakop2x”. And also a fond of playing basketball with his kuya and

friends. But today, he seldomly play those kind of games because of

his present situation where he gets easily tired and weak. Their only

fond now of hand plays such as “sikop2x”, “pusil2x”, image forming

shadows and art work.

5. Sleep-Rest

Before the onset of disease, according to his mother, the

patient's regular sleep timing is 8:00pm and wake-up at 7:00am. But

upon admission, the patient's usual sleeping pattern was altered

because of some unexpected awakening activities in the hospital and

sometimes because of patient's unhealthy condition.

6. Cognitive-Perceptual

The patient is only 2 years old. Upon assessment, he can able

identify things and person at his level, he wanted to be with his mother

and father always and wanted only to used his own spoon and plate.

This best described the nonoperational thought stage theory of

Piaget's sensory motor stage, wherein toddlers recognize that they are

separate beings by their mothers, but they are unable to assume the

view of another. They used symbols to represent objects, place, and

persons. When pt. JA and I play his toy which is the “turtle”, I asked

him like where's your eyes, mouth, arms, etc. and he was able to

answer it well. But when it comes to colors, he can't identify if what

color it is.

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7. Sexuality Reproductive

At the age of two, patient is still uncircumcised and the focus of

pleasure changes to the anal zone. Children became increasingly

aware of the pleasure sensations of this body region with interest to

the products of their effort. Through the toilet-training process the

child is asked to delay gratification in order to meet parenteral and

societal expectation.

8. Self Perception-Self Concept

Based on the conducted assessment, the patient was very much

possessive on the things he thought he owned, and wanted the full

attention of his parents. Jean Piaget's theory of cognitive development

period II : preoperational, this is the time when children's learn to think

with the used of symbols and mental images. Still, egocentric, the child

sees objects and persons from only one point of view, the child's own.

9. Role Relationship

Patient JA belongs to a simple family, having only one brother.

His mother work as and his father also. His role being the youngest

child was incorporated, process of communication was directly directed

to the recipient. He gave happiness to the family.

GENOGRAM(see appendix C, Figure 2)

10. Coping and Stress Tolerance

Based on my assessment, despite of the patient's anxiety on his

situation, he still able to make a smile and with the used of his toys

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and unlimited support and love of his parents he can still cope up with

his present situation.

11. Values and Belief

He is a Roman Catholic. He used to go to church every sunday

with his family. But sometimes, they can't go to church because of its

distance from their house.

The undeniable belief and faith of his parents made their family

ties really strong. The families belief that in spite of the turned/out

diagnoses of their child, cure will still be achieved. Because of their

strong faith in God, miracle is always in their heart.

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PHYSICAL ASSESSMENT

General Appearance (Assessed on June 17, 2009 at 7:00am)

Seen patient in bed, awake, conscious, responsive and coherent

with a sterile mask covering the ¾ of his entire face, coherent,

responsive, with an ongoing intravenous fluid of D5 IMB 500 ml/hr at

30gtts/min infusing well at right arm. With the following vital sign: T-

36.4 ºC, P-116bpm, R-42Cycles/min.

INTEGUMENTARY SYSTEM

The skin was fair complexion, uniform skin color, dry and warm.

The hair was black and evenly distributed. The scalp was symmetrical,

free of lesions; lumps or masses may feel normal, bony prominence on

the forehead, no masses or nodules. Nails were pale convex, smooth,

in good condition and had a capillary refill test result of less than 3

seconds.

HEAD AND NECK

Head was normocephalic, round and firm. The face has

symmetrical face features, smooth, was able to pop out cheeks with

symmetry, smiling and sometimes frowned. The neck was brown and

centrally aligned, able to flex, extend, hyperextend and move

sideways, and non tender.

EYES

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Eyes were watery, able to blink involuntary, able to move

together through the 6 cardinal fields of gaze.

EARS

Ears were c-shaped, aligned slightly above the outer canthus of

the eye, no lesions and non tender. Cerumen was present, light brown

and able to hear.

NOSE AND SINUS

Nose was brown, nares were patent, and non tender. Internal

nose appeared clean, septum at midline, sinuses were non tender.

Able to smell and identify correctly what has been smelled.

MOUTH AND OROPHARYNX

Lips were close symmetrically; dry and pale. Buccal mucosa was

pink and firm; gums were light pink and firm. Teeth were yellowish, in

good condition. The tongue was light pink, symmetrical, and able to

move without difficulty. Soft palate was light pink and firm.

THORAX AND LUNGS

The chest was brown, symmetrical; respiration are quite

effortless and regular sites and falls in unison w/ respiratory cycle of

42.

CARDIAC ASSESSMENT

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Pulse rate was 116bpm at radial site.

ABDOMEN

Abdomen was brown, no venous pattern; umbilicus was

protruding at midline, and non tender on palpation.

GENITOURINARY-REPRODUCTIVE SYSTEM

(NOT ASSESSED)

ANUS AND RECTUM

(NOT ASSESSED)

MUSCULOSKELETAL SYSTEM

ROM Upper Extremities- able to move up, down, and sideways

with assistance, able to flex and extend without assistance.

ROM Lower Extremities- able to flex, extend, move sideways, up,

down and rotate without assistance.

NEUROLOGIC SYSTEM

Patient was conscious, in good mood, speech was clear and

coherent, able to hear, smell, taste and understand commands.

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HUMAN ANATOMY AND PHYSIOLOGY

Humans can't live without blood. Without blood, the

body's organs couldn't get the oxygen and nutrients they need to

survive, we couldn't keep warm or cool off, fight infections, or get rid of

our own waste products. Without enough blood, we'd weaken and die.

Red blood cells (also called erythrocytes) are shaped like

slightly indented, flattened disks. RBCs contain the iron-rich protein

hemoglobin. Blood gets its bright red color when hemoglobin picks up

oxygen in the lungs. As the blood travels through the body, the

hemoglobin releases oxygen to the tissues. The body contains more

RBCs than any other type of cell, and each has a life span of about 4

months. Each day, the body produces new red blood cells to replace

those that die or are lost from the body.

Red Blood Cells (erythrocytes)

The most numerous type in the blood.

Women average about 4.8 million of these cells per cubic

millimeter (mm3; which is the same as a microliter [µl]) of blood.

Men average about 5.4 x 106 per µl.

These values can vary over quite a range depending on such

factors as health and altitude. (Peruvians living at 18,000 feet

may have as many as 8.3 x 106 RBCs per µl.)

RBC precursors mature in the bone marrow closely attached to a

macrophage.

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They manufacture hemoglobin until it accounts for some 90% of

the dry weight of the cell.

The nucleus is squeezed out of the cell and is ingested by the

macrophage.

No-longer-needed proteins are expelled from the cell in vesicles

called exosomes.

Thus, RBCs are terminally differentiated; that is, they can never

divide. They live about 120 days and then are ingested by phagocytic

cells in the liver and spleen. Most of the iron in their hemoglobin is

reclaimed for reuse. The remainder of the heme portion of the

molecule is degraded into bile pigments and excreted by the liver.

Some 3 million RBCs die and are scavenged by the liver each second.

Red blood cells are responsible for the transport of oxygen and carbon

dioxide.

Oxygen Transport

In adult humans the hemoglobin (Hb) molecule

consists of four polypeptides:

two alpha (α) chains of 141 amino acids and

two beta (β) chains of 146 amino acids

Each of these is attached the prosthetic group heme.

There is one atom of iron at the center of each heme.

One molecule of oxygen can bind to each heme.

The reaction is reversible.

Under the conditions of lower temperature, higher pH, and

increased oxygen pressure in the capillaries of the lungs, the

reaction proceeds to the right. The purple-red deoxygenated

hemoglobin of the venous blood becomes the bright-red

oxyhemoglobin of the arterial blood.

Under the conditions of higher temperature, lower pH, and lower

oxygen pressure in the tissues, the reverse reaction is promoted

and oxyhemoglobin gives up its oxygen.

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Carbon Dioxide Transport

95% of the CO2 generated in the tissues is carried in the red blood

cells:

It probably enters (and leaves) the cell by diffusion through the

plasma membrane assisted by facilitated diffusion through

transmembrane channels in the plasma membrane. (One of the

proteins that forms the channel is the D antigen that is the most

important factor in the Rh system of blood groups.)

Once inside, about one-half of the CO2 is directly bound to

hemoglobin (at a site different from the one that binds oxygen).

The rest is converted — following the equation above — by the

enzyme carbonic anhydrase into

bicarbonate ions that diffuse back out into the plasma and

hydrogen ions (H+) that bind to the protein portion of the

hemoglobin (thus having no effect on pH).

Only about 5% of the CO2 generated in the tissues dissolves

directly in the plasma. (A good thing, too: if all the CO2 we make were

carried this way, the pH of the blood would drop from its normal 7.4 to

an instantly-fatal 4.5)

When the red cells reach the lungs, these reactions are reversed and

CO2 is released to the air of the alveoli.

White blood cells (also called leukocytes) are a key part of the

body's system for defending itself against infection. They can move in

and out of the bloodstream to reach affected tissues. The blood

contains far fewer WBCs than red cells, although the body can increase

production of WBCs to fight infection. There are several types of WBCs,

and their life spans vary from a few days to months. New cells are

constantly being formed in the bone marrow.

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Several different parts of blood are involved in fighting infection.

White blood cells called granulocytes and lymphocytes travel along the

walls of blood vessels. They fight germs such as bacteria and viruses

and may also attempt to destroy cells that have become infected or

have changed into cancer cells.

Certain types of WBCs produce antibodies, special proteins that

recognize foreign materials and help the body destroy or neutralize

them. The white cell count (the number of cells in a given amount of

blood) in someone with an infection often is higher than usual because

more WBCs are being produced or are entering the bloodstream to

battle the infection. After the body has been challenged by some

infections, lymphocytes "remember" how to make the specific

antibodies that will quickly attack the same germ if it enters the body

again.

White Blood Cells (leukocytes)

are much less numerous than red (the ratio between the two is

around 1:700);

have nuclei;

participate in protecting the body from infection;

consist of lymphocytes and monocytes with relatively clear

cytoplasm, and three types of granulocytes, whose cytoplasm

is filled with granules.

Lymphocytes

There are several kinds of lymphocytes (although they all look alike

under the microscope), each with different functions to perform. The

most common types of lymphocytes are

B lymphocytes ("B cells"). These are responsible for making

antibodies.

T lymphocytes ("T cells"). There are several subsets of these:

inflammatory T cells that recruit macrophages and

neutrophils to the site of infection or other tissue damage

28

cytotoxic T lymphocytes (CTLs) that kill virus-infected

and, perhaps, tumor cells

helper T cells that enhance the production of antibodies

by B cells

Although bone marrow is the ultimate source of lymphocytes, the

lymphocytes that will become T cells migrate from the bone marrow to

the thymus where they mature. Both B cells and T cells also take up

residence in lymph nodes, the spleen and other tissues where they

encounter antigens;

continue to divide by mitosis;

mature into fully functional cells.

Monocytes

A white blood cell that has a single nucleus and can ingest (take

in) foreign material. In other words, a monocyte is thus a mononuclear

phagocyte that circulates in the blood. Monocytes later emigrate from

blood into the tissues of the body and there differentiate (evolve into)

into cells called macrophages which play an important role in killing of

some bacteria, protozoa, and tumor cells, release substances that

stimulate other cells of the immune system, and are involved in

antigen presentation.

Macrophages are large, phagocytic cells that engulf

foreign material (antigens) that enter the body

dead and dying cells of the body.

Neutrophils

The most abundant of the WBCs. Neutrophils squeeze through

the capillary walls and into infected tissue where they kill the invaders

(e.g., bacteria) and then engulf the remnants by phagocytosis.

This is a never-ending task, even in healthy people: Our throat, nasal

passages, and colon harbor vast numbers of bacteria. Most of these

are commensals, and do us no harm. But that is because neutrophils

keep them in check.

29

However,heavy doses of radiation, chemotherapy, and many other

forms of stress can reduce the numbers of neutrophils so that formerly

harmless bacteria begin to proliferate. The resulting opportunistic

infection can be life-threatening.

Eosinophils

The number of eosinophils in the blood is normally quite low (0–

450/µl). However, their numbers increase sharply in certain diseases,

especially infections by parasitic worms. Eosinophils are cytotoxic,

releasing the contents of their granules on the invader.

Basophils

The number of basophils also increases during infection. Basophils

leave the blood and accumulate at the site of infection or other

inflammation. There they discharge the contents of their granules,

releasing a variety of mediators such as:

histamine

serotonin

prostaglandins and leukotrienes

which increase the blood flow to the area and in other ways add to the

inflammatory process. The mediators released by basophils also play

an important part in some allergic responses such as

hay fever and

An anaphylactic response to insect stings.

Platelets

Platelets are cell fragments produced from megakaryocytes.

Blood normally contains 150,000–400,000 per microliter (µl) or cubic

millimeter (mm3). This number is normally maintained by a

homeostatic (negative-feedback) mechanism.

If this value should drop much below 20,000/µl, there is a danger of

uncontrolled bleeding.

30

Some causes:

certain drugs and herbal remedies;

autoimmunity.

When blood vessels are cut or damaged, the loss of blood from the

system must be stopped before shock and possible death occur. This is

accomplished by solidification of the blood, a process called

coagulation or clotting.

A blood clot consists of

a plug of platelets enmeshed in a

network of insoluble fibrin molecules.

Plasma

Plasma is the straw-colored liquid in which the blood cells are

suspended.

Composition of blood plasma

COMPONENTS PERCENT

Water ~92

Proteins 6–8

Salts 0.8

Lipids 0.6

Glucose

(blood

sugar)

0.1

Plasma transports materials needed by cells and materials that must

be removed from cells:

various ions (Na+, Ca2+, HCO3−, etc.)

glucose and traces of other sugars

amino acids

other organic acids

31

cholesterol and other lipids

hormones

urea and other wastes

Most of these materials are in transmit from a place where they are

added to the blood (a "source")

exchange organs like the intestine

depots of materials like the liver

to places ("sinks") where they will be removed from the blood.

every cell

exchange organs like the kidney, and skin

DIAGNOSTIC EXAM

URINALYSIS is an array of tests performed on urine and one of

the most common methods of medical diagnosis. A part of a urinalysis

can be performed by using urine dipsticks, in which the test results can

be read as color changes.

EXAM DESCRIPTION INTERPRETATION

Ionized

calcium

Used to monitor Ca

levels during and after

large volume of blood

transfusions.

Normal

SGPT/ALT Injury or disease

affecting the liver

parenchyma will cause

a release of this

hepatocellular enzyme

into the blood stream,

thus elevating serum

ALT levels

An increased level of SGPT

occurs when there is

Hepatitis

Hepatic necrosis

32

LDH Widely distributed

through the body, the

total LDH level is not a

specific indicator of any

one organ

An increased level of LDH

when there is

Leukemia

Or other particular

types of cancer or

diseases

ALP is a hydrolase enzyme

responsible for

removing phosphate

groups from many types

of molecules, including

nucleotides, proteins,

and alkaloids. The

process of removing the

phosphate group is

called

dephosphorylation.

Adults have lower levels of

ALP than

children because children's

bones are still growing.

During some growth spurts,

levels can be as high as 500

IU/L. Usually children are not

measured because of the

potential for such high

amounts, so the abnormal

results refer to adults.

BUN Measures the amount of

urea nitrogen in the

blood. Is formed in the

liver as the end product

of protein metabolism

normal

Creatinine Creatinine is a catabolic

product of creatinine

phosphate, which is

used in skeletal muscle

contraction.

normal

Sodium Determines the amount

of sodium excreted in

urine over 24hrs.

normal

33

Potassium Acid-based balance is

dependent on

potassium excretion to

a small degree.

normal

COMPLETE BLOOD COUNT is a test requested by a doctor or

other medical professional that gives information about the cells in a

patient's blood. A scientist or lab technician performs the requested

testing and provides the requesting Medical Professional with the

results of the CBC.

EXAM DESCRIPTION INTERPRETATION

WBC WBC is to fight infection

and react against

foreign bodies of tissues

A decreased total WBC

count occurs in many form,

overwhelming infection, and

autoimmune disease.

Neutro-

phil

A defend against

bacterial or fungal

infection and other very

small inflammatory

processes that are

usually first responders

to microbial infection;

their activity and death

in large numbers forms

pus.

Any deceased neutrophil

Overwhelming of

bacterial infection

lymphocyt

es

Lymphocytes are

distinguished by having

a deeply staining

Immunodeficiency

disease

leukemia

34

nucleus which may be

eccentric in location,

and a relatively small

amount of cytoplasm.

Monocytes Phagocytic cells capable

of fighting bacteria in a

way very similar to that

of neutrophils

monocytopenia

Eosinophil deals with parasitic

infections and an

increase in them may

indicate such.

Eosinophils are also the

predominant

inflammatory cells in

allergic reactions.

eosinopenia

Basophil Basophil/mast cell

capable of phagocytosis

of antigen- antibody

complexes. responsible

for allergic and antigen

response by releasing

the chemical histamine

causing inflammation.

Basopenia

Acute

allergic reaction

Stress reaction

Hemoglobi

n(Hgb)

Measure of the total

amount of hemoglobin in

the peripheral blood,

which reflects the

numbers of RBCs in the

blood.

Decreased Hgb level

anemia

35

Hematocrit

(Hct)

Measure of the

percentage of the total

blood volume that is

made up by the RBCs

Decreased hematocrit level

Anemia

Malnutrition

Leukemia

RBC RBC count is routinely

performed as part of a

complete blood count.

Where molecules of

hemoglobin that permit

the transport and

exchange of oxygen to

the tissues and carbon

dioxide from the tissues

A decrease RBC level

Signifies Anemia

Platelet

count

It is used to monitor the

course of the disease

Decreases platelet count

occurs when there is

leukemia

and other

myelofibrosis disorder

Pathophysiology

Host Agent Environment

>Male Continues division of cells

>2yrs old

excessive leukocyte precursor growth

Crowd out the normal marrow

36

Accumulation of immature

cells

Impaired bone marrow function

Bone

infiltration

Bone joint

pain

Neutropenia Thrombocytopenia Anemia

Increased infection impaired hemostasis

Susceptability

Increased bleeding

hypovolemia

Metastasis( dec. Blood

circulation)

Crowd out cellular proliferation

Of other cell

Liver Spleen

Lymph nodes

Hepatomegaly Splenomegaly

Lymphadenopathy

Erythrocytic Megakaryotic stem cells

stem cells immature WBC

Decrease RBC Decrease platelet Non-functional cells

Decrease defense against infection

Anemia Bleeding

37

Increased vulnerability to infection

*fever

sepsis

DEATH

NURSING CARE PLAN

Name of Patient: JA Sex: Male

Age: 2years old

NURSING

DIAGNOSIS/

NURSING INERVENTION EVALUATION

38

CUES

Altered

thermoregulatio

n related to

ongoing

infection

Objective Cue:

-WBC-1.34x10/L

-Unstable body

temp

-intermittent

fever

-temp: 36.4 ºC

-weak

1.Identify underlying cause

*to determine its appropriate

treatment.

2.Monitored core temperature

*to assess changes of

temperature.

3. Performed tepid sponge bath

*to decrease body

temperature.

4.Noted presence or absence

of sweating

*to prevent dehydration.

5. Maintained bed rest

*to promote wellness.

6.Administered antipyretic as

prescribed by the doctor

*to maintain gains and

continue progress if able.

7.Administered replacement

fluid and electrolytes as

prescribed

*to correct fluid and

electrolytes imbalance.

8. Discussed to the patient

together with the SO the

importance of adequate fluid

intake.

*to provide facts about

After nursing

intervention he

patient was able to

maintain a core

temperature within

normal range.

39

appropriate treatment.

Risk for injury

related to

abnormal blood

profile

secondary to

thrombocytope

nia

Subjective Cue:

........

Objective Cue:

Platelet=

131x10º/L

-fatigue

-weak

Imbalanced

Nutrition: less

thab body

requirements

related to

anorexia and

altered oral

mucous

membrane

Subjective Cue:

“Dakoon ni siya

sauna karon

1.Established rapport

*to promote good

communication.

2.Kept sharp objects away from

the patient

*to promote safe physical

environment and individual

safety.

3.Instructed the SO to have a

watcher to the patient

*to avoid further injury.

4.Raised side rails

* to prevent from injury.

5.Kept the floor dry

*to avoid injury and promote

safety.

1. Assessed for factors

contributing to altered

nutritional intake.

*Information about other

factors that may be altered or

eliminated to promote

adequate dietary intake is

provided.

2. Provide patient’s food

preferences within dietary

restrictions.

*Increased dietary intake is

After nursing

intervention the

patient together

with the SO was

able to

demonstrate

behaviours to

reduce risk factors

and protect self

from injury.

After nursing

intervention the

patient together

with the SO was

able to stimulate

his appetite.

40

nagniwang na

tungod sa iyang

sakit”, as

verbalized by

the mother.

Objective Cue:

-loss of appetite

-stated weight

loss(12kg. From

15.5kg)

-eating loss

-pale

encouraged.

3. Provide pleasant

surroundings at meal times.

*to enhance intake.

4. Prevent unpleasant

odors/sights.

*may have a negative effect on

appetite/eating.

5. Encourage client to choose

foods/have family member

bring foods that seem

appealing.

*to stimulate appetite.

Disturbed body

image: hair loss

related to post

chemo status.

Subjective Cue:

“nanglarut iya

buhok pero

ginagmay ra”

as verbalized

by the mother.

Objective Cue:

-hair loss

-pale

-weak

1. Encourage client to look and

touch affected body part.

*to begin to incorporate

changes into body image.

2. Encourage client for

verbalization.

*to enhance handling of

potential situations.

3. Instruct patient significant

others to purchase a wig or

hats.

*to enhance appearance

4.Instruct to put up on

sunscreen

*to prevent sunburns since

patient has sensitive skull

5. Comfort patient in knowing

that his hair will grow back

After nursing

intervention the

patient together

with the SO was

able to verbalize

adaptation to

actual or altered

body image.

41

Deficient

Knowledge

regarding

disease process

related to lack

of information.

Subjective Cue:

“ambot nikalit

raman gud ni

siya, luya siya

tan.awn

permente og

manluspad”, as

verbalized by

the mother.

*to enhance self confidence.

1. Determine pt. /S.O

perception of cause of AML.

*Establishes knowledge base

and provides some insight info.

How the teaching plan needs to

be constructed for this

individual.

2. Provide/review info.

Regarding etiology of AML

cause/effect, relationship of

lifestyle behaviours and ways

to reduce risk/

contributing factors.

*provides knowledge base from

which pt. /S.O can make

informed choices/decisions

about future and control of

health problems.

3. Instruct pt. / S.O to use mask

or protective equipments.

*reducing spread of infection.

4. Refer to support groups/

counselling for

lifestyle/behaviour changes,

reduction of associated risk

factors.

*for proper management.

After nursing

intervention the

patient together

with the SO was

able to verbalize

understanding of

cause of AML,

treatment

modalities and

identify/ implement

necessary lifestyle

changes.

CHAPTER III

42

SUMMARY OF FINDINGS, PROGNOSIS,

RECOMMENDATIONS/DISCHARGE PLAN

SUMMARY OF FINDINGS

Health was defined as being defined as "a state of complete

physical, mental, and social well-being and not merely the absence of

disease or infirmity". But one of the most difficult life changes which

we will face is when one of the family members is being ill or was

diagnosed with terminal illness. During this problem, it is important to

have a friend or a family member who will support you and give you

strength. Of course the nurse plays the most vital role in caring. The

nurse must give care to the patient holistically and not just curing the

disease. Caring must involve the physical, psychological, social,

emotional and spiritual aspect of the person.

The purpose of this study is to be aware of the different

manifestations of the disease, the precipitating factors that led for the

patient to acquire the disease, the different signs and symptoms of

Acute Myelocytic Leukemia, the nursing diagnoses formulated for the

disease and the interventions provided to the patient in response to

the diagnoses formulated.

Different pharmacologic and nursing management were done to

the patient. The medications given were clarythromycin and

paracetamol. Clarithromycin is useful in acute worsening of chronic

bronchitis, community acquired pneumonia. And also used to treat

uncomplicated skin and skin structure infections. Paracetamol for the

relief of mild to moderate pain, fever, migraine, tension, headaches

Nursing management includes action interventions such as

passive, ROM exercises and assistance in performance of his ADLs.

Intervention in the environment was also done such as keeping the

room quiet and cool, and limits visiting hours.

43

PROGNOSIS

Acute Myeloid Leukemia can be controlled and sometimes cured.

Its prognosis depends on a variety.

AML can be kept in remission for a long period of time or even

cured in some adults. Depending on certain factors such as, the

characteristics of the leukemia cells. Some patients have a better

prognosis in comparison to others.

RECOMMENDATIONS

Based on findings and conclusions made, the researchers

advance the following recommendations:

1. That this research may be implemented for the people to

further understand the disease process of Acute Myelocytic

Leukemia.

2. Propose a guideline to prevent the disease or to lessen the

manifestations of the disease process.

44

DISCHARGE PLAN

Objectives Nursing intervention

By the time the patient will be

discharged on the hospital, he will

be able to:

M- Take home meds.

E- Maintain a safe environment.

To explain to the pt. and to

his S.O the prescribed

medications with their

nature and effects.

*Clarythromycin

- macrolides

-125/5 4ml –P.O B.I.D

*Paracetamol

-Nonopioid analgesics and

antipyretics

-250/5ml, 4ml every 4hrs prn

Instruct the mother/ s.o to

prepare foods that is not

contaminated with infectious

agents.

Demonstrate proper

handwashing.

45

-Keep a clean and well sanitized

environment

T-Continuing the appropriate

treatments and follow-up check-

up

H- Discuss the importance/ factors

that tend toward the cause and

effects of his disease

-wet hands with

uncontaminated water

-apply soap

-rub hands together, interlacing

each finger

-rinse hands

-dry hand thoroughly using

clean cloth

*Handwashing should be done

during food prep. And after using

the toilet to avoid spreading of

microorganism.

Emphasize to the s.o of the

pt. the importance of

maintaining a clean and well

sanitized environment to

prevent from acquiring

microorganism that could

alter their health status.

Encourage pt and his family

the importance of having

follow-up check-up and

continuous of the

appropriate treatments.

Explain to the pt. and his

family the importance/ risk

factors that lead to the

46

O-Observe the signs and

symptoms of the disease

existence of his disease

(AML (Acute Myelocytic Leukemia)

is a cancer that starts in cells that

would normally develop into

different types of blood cells. Most

cases of AML develop from cells

that would turn into white blood

cells (other than lymphocytes), but

some cases of AML develop in

other types of blood-forming cells.

AML starts in the bone marrow

(the soft inner part of the bones,

where new blood cells are made),

but in most cases it quickly moves

into the blood. It can sometimes

spread to other parts of the body

including the lymph nodes, liver,

spleen, central nervous system

(brain and spinal cord), and testes.

)

Explain to the pt. and his

family the signs and

symptoms of the disease

- Tiredness or no energy

-Shortness of breath during

physical activity

-Pale skin

-Swollen gums

47

D-Identify the appropriate diet

towards the recovery of the pt.

S- Improve spiritual well being

towards personal beliefs and

values

-Slow healing of cuts

-Pinhead-size red spots under the

skin

-Prolonged bleeding from minor

cuts

-Mild fever

-Black-and-blue marks (bruises)

with no clear cause

-Aches in bones or knees, hips or

shoulder.

Encourage the pt. & S.O to

eat nutritious foods that is

good for health like eating

vegetables(squash,green-

leafy vegetables,etc.) and

fruits(orange,apple,grapes,et

c)

Encourage the pt. and his

family to acquire spiritual

growth and beliefs(attending

masses every

Sunday,praying novena).

48

LEARNING INSIGHTS

49

BIBLIOGRAPHY

http://www.cancer.gov/cancertopics/pdq/treatment/childAML/Patient

http://www.merck.com/

http://emedicine.medscape.com/article/987228-overview

http://www.nlm.nih.gov/medlineplus/ency/article/000542.htm

Doenges, Marilyn E., Moorhouse, Mary Frances, and Murr, Alice.Nurse’s

Pocket Guide (Diagnoses, Prioritized Interventions, and Rationlae). 10th

edition.Copyright ©2006 by F.A Davis Company.

Black, Joyce M. And Hawks, Jane H. Medical Surgical Nursing (Clinical

Management for positive Outcomes). 7th edition. Copyright 2005 by

Elsevier Inc.

Nursing 2008 Drug Handbook. 28th edition. Copyright Lippincott

Williams and Wilkins

50

American Cancer Society. Cancer Facts and Figures 2007. Atlanta, GA:

American Cancer Society; 2007

APPENDICES

Appendix A

COMPLETE BLOOD COUNT

TEST RESULT NORMAL RANGE

WBC 1.34 4,500-11,000/mm3

Neutrophils 7 40-75%(2,500-7,500/mm3)

Lymphocytes 0 20-50%(1,500-5,500/mm3)

Monocytes 1 1-10%(100-800/mm3)

Eosinophils 0 0-6%(0-440/mm3)

Basophils 0 0-2%(0-200/mm3)

Hemoglobin 8.9 M: 13.5-17.5 g/dl

51

F: 11.5-15.5 g/dl

Hematocrit 24.8 M: 40-52%

F: 36-48%

RBC 4.2 M: 4.7-6.1x10.6/uL

F: 4.2-5.4x10.6/uL

Platelet 131x10º/L 150-400x10º/L

URINALYSISTEST RESULT NORMAL RANGE

Ionized calcium 1.25mmol/L 1.20-1.38mmol/L

SGPT/ALT 67.00 U/L 4-36 U/L

LDH 1061.9 U/L 0 - 250 U/L

ALP 192.874IU/L 20 to 140 IU/L

BUN 3.93mmol/L 1.7-8.3mmol/L

Creatinine 30.06mmol/L 53.04-132.6mmol/L

52

Sodium 136mmol/L 40-220mmol/L

Potassium 3.88mmol/L 3.4-5.2mmol/L

Appendix B

DRUG STUDY

NAME OF DRUG INDICATIONS SIDE EFFECTS

clarithromycin

(Biaxin)

Anti-infectives

Clarithromycin is useful

in acute worsening of

chronic bronchitis,

community acquired

pneumonia. And also

used to treat

uncomplicated skin and

skin structure infections.

Headache

Diarrhea

Abdominal

pain or

discomfort

Nausea

vomiting

rash

53

acetaminophen

(Paracetamol)

analgesic, antipyretic

for the relief of mild to

moderate pain, fever,

migraine, tension,

headaches

Side effects of

paracetamol are

rare. Uncommon

side effects

include

indigestion,

nausea, rashes.

Flow of the Study

Input

Throughput/Process

Output

A case of 2 year

old, male patient

diagnosed with

Acute Myelocytic

Leukemia.

He complained of

persistent on and

off fever, and

cough thus

prompted his

admission.

He has no known

heredo-familial

disease.

54

Figure 1

Schematic Diagram

Appendix C

Appendix C

Figure 2

GENOGRAM:

Legend:

-Female

DM - Diabetes

Mellitus

- Male

HPN -

Hypertension

- Patient(male)

A - Asthma

† - Died AML -Acute Myelocytic

Leukemia

Management

Medical

Management

Pharmacological

Treatment

Recommendations:

The patient/S.O is

advised to always

maintain a clean

environment, limit

visitors, and do ROM

exercises and

assistance in

performance of

patient’s activities of

daily living.

Prognosis:

Good- if treated

immediately with

chemotherapy and

medical mgt.

Poor- if untreated

immediately, it would

lead to sepsis then

eventually death.

HPN

ADM

55

Appendix D

CURRICULUM VITAE

A

AML