chronicmyeloid leukemia
TRANSCRIPT
7/30/2019 ChronicMyeloid Leukemia
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P R E S E N T E D B Y :
J O H N J O S E P H O . D E G U Z M A N , R . N
J A Y B E E B E R N A N D I N O , R . N
C A T H Y T . R O X A S , R . N
Chronic Myeloid Leukemia
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Patient’s Profile:
53 y/o male
Married, with 3 children
Admitted on July 13 2012 Male Medical Service Ward
Dx: Chronic Myelogenous Leukemia
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History
Pt. has an active lifestyle
Occupation: farmer No history of hypertension ordiabetes
Non-smoker Drinks alcohol during some occasions
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does not have history of
hospitalization the past yearexcept for clinic visits due to cough andcold
May 2012, the patient observed easy fatigability and mild dyspnea when doing activities of daily living heused to do
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July 13 2012, the patient experiencedsevere difficulty of breathing. Thefamily decided to seek medical attentionand brought him to a secondary levelhospital.
The hospital then referred the patient to atertiary level after administering
oxygen therapy and stabilizing his vitalsigns.
The doctor then ordered CBC, Xray,ECG and put him on oxygen and
complete bed rest without BRP
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(input date)Laboratory findings and furtherassessments confirmed that patient has Chronic
Myeloid Leukemia and was then prompt forconfinement.
He was advised to start chemotherapy once he is in better condition to do so.
___ sir nlgay ko n din toh kse un ksunod n sttmntcnbi ntin n pnstop nia un chemo so i gues ok lng naadd toh. – un lng nmn =) sorry toxic ha! =p
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Due to financial incapability , on
August 12, 2012, the patient askedthe physician to withdraw allchemotherapeutic treatment except
palliative treatments.
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Nursing Assessment:
Health Perception and Health
Management Pattern Before the patient was diagnosed, the patient
describes his health status as good.
He is a non-smoker and an occasional drinker.
He never used drugs. He describes his living condition as fair. The past
months prior to admission, he experienced frequentcough and cold and seeks medical attention forsymptoms cannot be treated by home remedies.
The patient manages minor pain symptoms by taking over the counter medications for pain.
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Nursing Assessment:Nutrition and Metabolic Pattern
Pt eats 4 times a day. Before admission, his mealusually has a balanced mix of fruits and vegetables with meat served seldom.Experienced weight loss of around 30kg in thelast 6mos
Usually takes 6 to 8 glasses of water a day
At present, patient describes appetite as fair
sometimes experiencing nausea and vomiting
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Nursing assessment:Elimination Pattern
The patient was having hematuria and melenaprior to admission
Patient defecates twice to thrice per day with no
regular schedule (-) retention and no difficulty defecating
Sometimes experiencing incontinence
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Nursing Assessment: Activity or Exercise Pattern
Generally, because of weakness, the patientrequires assistance in most of the ADLs
Patient experiences weakness even after a talking
to somebody He is bedridden and requires oxygen to breathe.
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Nursing Assessment:Sleep Rest Pattern
The patient sleeps 6 hours at night usually with periods of naps during daytime and hefinds no difficulty sleeping
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Nursing Assessment:Cognitive-Perceptual Pattern
Patient is able to read and write
Able to understand physician instructionsregarding medical regimen
Drowsy most of the time Sometimes patient experiences epigastric pain but
is relieved by pain medications
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Nursing Assessment:Self-perception and Self-Concept Pattern
Death is the major concern of the patient andfamily
If recovered, the patient expects a huge change of
lifestyle like wearing mask and strict infectionprecaution practices
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Nursing Assessmen:Role Relationship Pattern
The patient resides with his family in Quezon,Nueva Ecija
The patient has a number of friends in the
community that he frequently interact with, but because of the illness, the patient is afraid that hecould not interact with them as frequent as before
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Nursing Assessment:Sexuality and Reproductive Pattern
The patient before admission assumes therole of a man thru being a father andhusband to his children and wife.
He is the provider of the family then.
After being aware that he will be
bedridden most of the time, he cameto acceptance that he cannot provideanymore for the family
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Nursing Assessment:Coping- Stress Tolerance Pattern
The patient have experienced many stressfulevents in the past and he responds thruconfronting the problem
With regards to family problems, he often talksto his wife or children before coming up with asolution
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Nursing Assessment: Value-Belief Pattern
The patient is a Roman Catholic and believesthat God will never leave him throughout theillness
The illness does not interfere with his belief orreligious practices.
He still finds time to pray and talk to a lay eucharistic minister who sometimes visit him in
the hospital
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Anatomy and Physiology of theImmune System
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Functions:
• Protection against invasion of microorganismfrom outside the body
• Protects the body from internal threats and
maintains the internal environment by removing dead or damaged cells
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The immune system defends the body from invading organisms that may
cause disease. One part of the immunesystem uses barriers to protect the body from foreign substances. These barriersinclude the skin and the mucous
membranes, which line all body cavities;and protective chemicals, such asenzymes in saliva and tears that destroy
bacteria. Another part of the immune
system uses lymphocytes, specialized white blood cells that respond to specifictypes of foreign invaders.
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B LYMPHOCYTESPRODUCE PROTEINS
CALLED ANTIBODIES, WHICH CIRCULATE IN
THE BLOOD AND ATTACK SPECIFIC DISEASE-
CAUSING ORGANISMS. TLYMPHOCYTES ATTACK INVADING ORGANISMS
DIRECTLY.
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First lines of defence
skin preventsentry
tears antibacterialenzymes
saliva antibacterialenzymes
stomach acid low pH killsharmfulmicrobes
mucus linings
traps dirt andmicrobes
“good” gutbacteria outcompete bad
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Second lines of defence
Involves white blood cells
Non-specific response invading pathogens are
targeted by macrophages
Specific response lymphocytes produce chemicals
called antibodies that targetspecific pathogens
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Components
Macrophages
Lymphocytes
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Lymphocytes
Lymphocytes are specialized white blood cells whosefunction is to identify and destroy invading antigens.
All lymphocytes begin as ―stem cells‖ in the bone
marrow Other lymphocytes, called T lymphocytes, or T cells,
mature in the thymus, a small glandular organlocated behind the breastbone.
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Some T lymphocytes, called cytotoxic
(cell-poisoning) or killer T lymphocytes, generate cell-mediatedimmune responses, directly destroyingcells that have specific antigens on their
surface that are recognized by the killerT cells. Helper T lymphocytes, asecond kind of T lymphocyte, regulatethe immune system by controlling the
strength and quality of all immuneresponses.
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Most contact between antigens and
lymphocytes occurs in the lymphoid organs—the lymph nodes, spleen, andtonsils, as well as specialized areas of theintestine and lungs (see Lymphatic
System). Mature lymphocytes constantly travel through the blood to the lymphoidorgans and then back to the blood again.This recirculation ensures that the body is
continuously monitored for invadingsubstances.
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The Bone Marrow
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The Bone Marrow
Bone Marrow, soft, pulpy tissue that fills the cavitiesof 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 adult’s weight. Redmarrow, present in all bones at birth, serves as the blood manufacturing center. As an infantmatures, 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 iscomposed primarily of specialized fat cells.
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The Bone Marrow
While not usually actively involved in blood formation, in an emergency yellow
marrow is replaced by blood-formingred marrow when the body needs more
blood
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Pathoph siolog
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Pathophysiology
Predisposing Factors:Possible Familial Tendency
Precipitating Factors:Exposure to Chemical Fertilizers
Myeloblast transformation
Continuous accumulation of immature cells
Splenomegaly,Hepatomegaly, BonePain
Crowd out cellularproliferation of other cells
Decreased WBC and
Platelet
Anemia andThrombocytopenia
Hypermetabolism
Weight LossNon-functioningcells
Decreased defense
against infection
Fever
Diagnostics
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Diagnostics
Pt Result Ref
WBC 360.7 5- 10 x 109/L
RBC 2.49 4.5-6.0 x
10
12
/LHematocrit 0.21 .40-.54%
Hemoglobin 106 120-170 g/L
Platelet 535 150-450x10
9
/LLymphocytes 0.12 .20-.40
Monocytes 0.14 0-0.07
Hematology
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Urinalysis
Physical Examination: Color: Yellow
Transparency: Slightly Turbid
Reaction 5.0 Specific Gravity: 1.025
Microscopic Examination: Pus Cells: 20-25 HPF
Red Cells: 2-4 HPF
Epithelial Cells: Few
Diagnostics
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Chronic Myeloid Leukemia
Risk for
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Subjective:
“Madalas akong magkaroon ng lagnat, ubo at sipon
kahit nuon pa man, mga ilang buwan bago ako na-
confine.” as stated by the patient.
Objective:
• Abnormally elevated WBC ( 360.7 x 109 /L
• Decreased Lymphocytes and Monocytes
Risk for
Infection
Risk for
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Risk for infectionrelated to inadequate
secondary defenses
Risk for
Infection
Risk for
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• After 8 hours of nursing intervention,
patient will have reduced risk of local and
systemic infection as evidenced by:
• Understanding of causative risk factors
• Identification of interventions that reduces the
risk of infection
• Compliance with preventive measures; and• Prompt reporting of early signs and symptoms
Risk for
Infection
Risk for
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INTERVENTIONS RATIONALE
ONGOING ASSESSMENT:
• Auscultate lung fields for crackles,
ronchi and decreased lung sounds
• Inspect body sites with high
infection potential
• Monitor temperature as indicated
• Pulmonary infections are common
• Many infections that occur in patient
with leukemia are opportunistic dueto immunocompression.
• Fever is a sign of infection and
sometimes the first symptom to
manifest
THERAPEUTIC INTERVENTIONS:
• Explain the cause and effect of
leukopenia
• Instruct the client to maintain
personal hygiene: hand washing,
oral care and perineal care.
• Leukemic cells replace normal
cells.
• This reduces transient and resident
bacteria that may cause infection
Risk for
Infection
Risk for
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INTERVENTIONS RATIONALE
• Instruct the patient and
primary caregiver
regarding the importance
of eliminating potentialsources of infection
• Avoidance of patient
contact with family or
visitor with flu• Avoidance of shared
drinking and eating
utensils
• Instruct patient to wear
face mask
• Patient must understand
the measures by which
they can protect
themselves during times of compromised defense
Risk for
Infection
Risk for
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• Goal met if After 8 hours of nursing
intervention, patient have reduced risk of
local and systemic infection as evidenced
by:• Understanding of causative risk factors
• Identification of interventions that reduces the
risk of infection• Compliance with preventive measures; and
• Prompt reporting of early signs and symptoms
Risk for
Infection
Fatigue
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Subjective:
“Madali akong mapagod, katunayan kahit nakikipag-usap
ako, ilang minuto lang nanghihina na ako.”
Objective:
• Hemoglobin = 106 g/L
• Weakness
• Exertional dyspnea
Fatigue
Fatigue
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Fatigue related to reduced oxygen
carrying capacity of blood as
evidenced by report of weakness
and exertional dyspnea
Fatigue
Fatigue
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• After 8 hours of nursing intervention, thepatient will:
• Report improved sense of energy
• Identify basis of fatigue an individual areas of control
• Establishes a pattern of sleep and rest that
facilitates optimal performance of required or
desired activities
Fatigue
Fatigue
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Fatigue
INTERVENTIONS RATIONALE
• Assist patient in planning ADLs.
Guide in prioritizing activities for the
day
• Not all self care activities need to
be completed in the morning
• Teach energy conservation
principles
• Patient may need to learn skills for
delegation of task to others, settingpriorities and clustering of activities
• Assist patient with self care needs
ambulation as necessary
• Discuss routines to promote sleep • Sleep is important to regain energy
• Educate stress management skills
of visualization, relaxation and
biofeedback
• To aid in establishing comfort and
conditions conducive to relaxation
• Instruct client to monitor responses
to activity and significant signs and
symptoms
• Indicates the need to alter activity
Fatigue
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• After 8 hours of nursing intervention, the
patient:
• Reported improved sense of energy
• Identified basis of fatigue an individual areas of
control
• Established a pattern of sleep and rest that
facilitates optimal performance of required or desired activities
Fatigue
Deficient
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SUBJECTIVE:
““ Ano ba talaga ang dahilan bakit ako
nagkasakit ng ganito?” As stated by thepatient.
Deficient
Knowledge
Deficient
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Deficient knowledgerelated to new disease
Deficient
Knowledge
Deficient
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• After 4 hours of nursing interventions,
the patient will verbalize
understanding to the disease’s:
•Diagnosis
•Treatment Strategies; and
•Prognosis
Deficient
Knowledge
Fatigue
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Fatigue
INTERVENTIONS RATIONALE
ONGOING ASSESSMENT
• Assess knowledge of disease,
treatment strategies and prognosis
• Several types of leukemia occur
which can be confusing
THERAPEUTIC INTERVENTION
• Describe the etiology of leukemia• Explain the blood-forming changes
that occur with all types of leukemia
• Clarify the difference between acute
and chronic leukemia
• Describe the patient’s specific type
of leukemia
• These needs to be explained to thepatient to gain understanding of the
disease
Deficient
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Deficient
Knowledge
• After 4 hours of nursing interventions,
the patient verbalized understanding
to the disease’s:
•Diagnosis
•Treatment Strategies; and
•Prognosis
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Calcium
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• Antacid, calcium
supplement,osteoporosis
Calcium
Carbonate
Calcium
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• Decreases total acid load of GI
tract.
• Increase esophageal sphincter
tone
Calcium
Carbonate
Calcium
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•Hypercalcemia
• bone tremors
•severe renal failure
• hypersensitivity
Calcium
Carbonate
Ceftriaxon
Calcium
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• PRECAUTION:
• History of stone formation, pregnancy
• ADVERSE RXN
• Constipation, flatulence, diarrhea,
renal dysfunction, acid rebound
Ceftriaxon
e
Calcium
Carbonate
Ceftriaxon
Calcium
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• administer as antacid 1 hr fter meal
and at bed time
• administer as supplement 1 ½ hrsafter meal and at bed time
• advice pt to increase fluids to 2L
unless contraindicated
•
Ceftriaxon
e
Calcium
Carbonate
Ceftriaxon
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Inhibits bacterial wall
synthesis
Ceftriaxon
e
Ceftriaxon
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Gram negative infections; Meningitis,
Gonorrhea. Bone and joint infections,
Lower respiratory tract infections,middle ear infection, PID, Septicemia
and Urinary Tract infections.
e
Ceftriaxon
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Patients hypersensitive to
cephalosporins, penicillins and
related antibiotics. Pregnancy(Category B). Breastfeeding
women.
e
Ceftriaxon
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• phlebitis
• diarrhea, abdominal cramps,
pseudomembranous colitis, biliarysludge
• Genital pruritus; moniliasis
• eosinophilia, thrombocytosis,leukopenia
• pain, indurations, tenderness, rash
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Ceftriaxon
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• determine hypersensitivity reactions
• periodic coagulation studies (PT and INR)should be done.
• inject in large muscles, such as gluteusmaximus or lateral aspect of thigh androtate sites.
• report signs such as petechiae, ecchymoticareas, epistaxis or other forms of unexplained bleeding.
• instruct to avoid alcohol use
e