LEUKEMIA CASE STUDY

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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 thoroughly and comprehensively all the
gathered relevant data and relate them both to client and his existing conditions.

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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
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

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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 factors in the
case of illness

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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).
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

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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:
• 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).

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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, Management Recommendations:
male patient • Medical The patient/S.O is
diagnosed with Management advised to always
Acute Myelocytic • Pharmacological maintain a clean
Leukemia. Treatment environment, limit
visitors, and do ROM
He complained of exercises and assistance
persistent on and off in performance of
fever, and cough patient’s activities of
thus prompted his daily living.
admission. Prognosis:
Good- if treated
He has no known immediately with
heredo-familial chemotherapy and
disease. medical mgt.
Poor- if untreated
immediately, it would
lead to sepsis then
eventually death.
Figure 1
Schematic Diagram
DEFINITION OF MEDICAL/ NURSING TERMS

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• 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
• 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.

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•
• Acute leukemia- A rapidly progressing cancer that starts in blood-formi
tissue such as the bone marrow, and causes large numbers of white blood ce
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 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.

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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.
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.

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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 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.

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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 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

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“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.
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.

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4. Activity Exercise
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 and unlimited support
and love of his parents he can still cope up with his present situation.

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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
Eyes were watery, able to blink involuntary, able to move together
through the 6 cardinal fields of gaze.

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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
Pulse rate was 116bpm at radial site.
ABDOMEN

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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.
• They manufacture hemoglobin until it accounts for some 90% of the dry
weight of the cell.

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• 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.
Carbon Dioxide Transport
95% of the CO2 generated in the tissues is carried in the red blood cells:

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• 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.
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.

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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
• 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

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• 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.
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.

27. 27
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.
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

28. 28
• 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 0.1
sugar)
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
• 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

29. 29
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 Used to monitor Ca levels Normal
calcium during and after large
volume of blood
transfusions.
SGPT/ALT Injury or disease affecting An increased level of SGPT occurs
the liver parenchyma will when there is
cause a release of this • Hepatitis
hepatocellular enzyme into • Hepatic necrosis
the blood stream, thus
elevating serum ALT levels
LDH Widely distributed through An increased level of LDH when
the body, the total LDH there is
level is not a specific • Leukemia
indicator of any one organ • Or other particular types of
cancer or diseases
ALP is a hydrolase enzyme Adults have lower levels of ALP
than
responsible for removing
phosphate groups from children because children's bones
many types of molecules, are still growing. During some
including nucleotides, growth spurts, levels can be as
proteins, and alkaloids. The high as 500 IU/L. Usually children
process of removing the are not measured because of the
phosphate group is called potential for such high amounts,

30. 30
dephosphorylation. so the abnormal results refer to
adults.
BUN Measures the amount of normal
urea nitrogen in the blood.
Is formed in the liver as the
end product of protein
metabolism
Creatinine Creatinine is a catabolic normal
product of creatinine
phosphate, which is used in
skeletal muscle contraction.
Sodium Determines the amount of normal
sodium excreted in urine
over 24hrs.
Potassium Acid-based balance is normal
dependent on potassium
excretion to a small degree.
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 A decreased total WBC count
react against foreign bodies occurs in many form,
of tissues overwhelming infection, and
autoimmune disease.

31. 31
Neutro- A defend against bacterial Any deceased neutrophil
phil or fungal infection and • Overwhelming of
other very small bacterial infection
inflammatory processes that
are usually first responders
to microbial infection; their
activity and death in large
numbers forms
pus.
lymphocytes Lymphocytes are • Immunodeficiency
distinguished by having a disease
deeply staining nucleus • leukemia
which may be eccentric in
location, and a relatively
small amount of cytoplasm.
Monocytes Phagocytic cells capable of • monocytopenia
fighting bacteria in a way
very similar to that of
neutrophils
Eosinophil deals with parasitic • eosinopenia
infections and an increase in
them may indicate such.
Eosinophils are also the
predominant inflammatory
cells in allergic reactions.
Basophil Basophil/mast cell capable • Basopenia
of phagocytosis of antigen- • Acute
antibody complexes.
responsible for allergic and • allergic reaction
antigen response by • Stress reaction
releasing the chemical

32. 32
histamine causing
inflammation.
Hemoglobin( Measure of the total amount Decreased Hgb level
Hgb) of hemoglobin in the • anemia
peripheral blood, which
reflects the numbers of
RBCs in the blood.
Hematocrit( Measure of the percentage Decreased hematocrit level
Hct) of the total blood volume • Anemia
that is made up by the RBCs • Malnutrition
• Leukemia
RBC RBC count is routinely A decrease RBC level Signifies
performed as part of a Anemia
complete blood count.
Where molecules of
hemoglobin that permit the
transport and exchange of
oxygen to the tissues and
carbon dioxide from the
tissues
Platelet It is used to monitor the Decreases platelet count occurs
count course of the disease when there is
• leukemia
• and other myelofibrosis
disorder
Pathophysiology

33. 33
Host Agent Environment
>Male Continues division of cells
>2yrs old
excessive leukocyte precursor growth
Crowd out the normal marrow
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

34. 34
Decrease defense against infection
Anemia Bleeding
Increased vulnerability to infection
*fever
sepsis
DEATH
NURSING CARE PLAN

35. 35
Name of Patient: JA Sex: Male
Age: 2years old
NURSING NURSING INERVENTION EVALUATION
DIAGNOSIS/
CUES
Altered 1.Identify underlying cause After nursing
thermoregulation *to determine its appropriate intervention he
related to ongoing treatment. patient was able to
infection 2.Monitored core temperature maintain a core
Objective Cue: *to assess changes of temperature. temperature within
-WBC-1.34x10/L 3. Performed tepid sponge bath normal range.
-Unstable body *to decrease body temperature.
temp 4.Noted presence or absence of
-intermittent fever sweating
-temp: 36.4 ºC *to prevent dehydration.
-weak 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 appropriate

36. 36
treatment.
Risk for injury 1.Established rapport After nursing
related to *to promote good communication. intervention the
abnormal blood 2.Kept sharp objects away from the patient together with
profile secondary patient the SO was able to
to *to promote safe physical demonstrate
thrombocytopenia environment and individual safety. behaviours to reduce
3.Instructed the SO to have a risk factors and
Subjective Cue: watcher to the patient protect self from
........ *to avoid further injury. injury.
4.Raised side rails
Objective Cue: * to prevent from injury.
Platelet= 5.Kept the floor dry
131x10º/L *to avoid injury and promote
-fatigue safety.
-weak
Imbalanced 1. Assessed for factors contributing After nursing
Nutrition: less to altered nutritional intake. intervention the
thab body *Information about other factors patient together with
requirements that may be altered or eliminated to the SO was able to
related to promote adequate dietary intake is stimulate his appetite.
anorexia and provided.
altered oral 2. Provide patient’s food
mucous preferences within dietary
membrane restrictions.
*Increased dietary intake is
Subjective Cue: encouraged.
“Dakoon ni siya 3. Provide pleasant surroundings at
sauna karon meal times.

37. 37
nagniwang na *to enhance intake.
tungod sa iyang 4. Prevent unpleasant odors/sights.
sakit”, as *may have a negative effect on
verbalized by the appetite/eating.
mother. 5. Encourage client to choose
foods/have family member bring
Objective Cue: foods that seem appealing.
-loss of appetite *to stimulate appetite.
-stated weight
loss(12kg. From
15.5kg)
-eating loss
-pale
Disturbed body 1. Encourage client to look and After nursing
image: hair loss touch affected body part. intervention the
related to post *to begin to incorporate changes patient together with
chemo status. into body image. the SO was able to
2. Encourage client for verbalize adaptation
Subjective Cue: verbalization. to actual or altered
“nanglarut iya *to enhance handling of potential body image.
buhok pero situations.
ginagmay ra” as 3. Instruct patient significant others
verbalized by the to purchase a wig or hats.
mother. *to enhance appearance
Objective Cue: 4.Instruct to put up on sunscreen

38. 38
-hair loss *to prevent sunburns since patient
-pale has sensitive skull
-weak 5. Comfort patient in knowing that
his hair will grow back
*to enhance self confidence.
Deficient 1. Determine pt. /S.O perception of After nursing
Knowledge cause of AML. intervention the
regarding disease *Establishes knowledge base and patient together with
process related to provides some insight info. How the the SO was able to
lack of teaching plan needs to be verbalize
information. constructed for this individual. understanding of
2. Provide/review info. Regarding cause of AML,
Subjective Cue: etiology of AML cause/effect, treatment modalities
“ambot nikalit relationship of lifestyle behaviours and identify/
raman gud ni and ways to reduce risk/ implement necessary
siya, luya siya contributing factors. lifestyle changes.
tan.awn permente *provides knowledge base from
og manluspad”, which pt. /S.O can make informed
as verbalized by choices/decisions about future and
the mother. 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.

39. 39
CHAPTER III
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.

40. 40
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.

41. 41
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. ♥ 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
E- Maintain a safe environment. ♥ Instruct the mother/ s.o to
prepare foods that is not
contaminated with infectious
agents.
♥ Demonstrate proper
handwashing.
-wet hands with uncontaminated
water

42. 42
-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.
-Keep a clean and well sanitized ♥ Emphasize to the s.o of the pt.
environment the importance of maintaining a
clean and well sanitized
environment to prevent from
acquiring microorganism that
could alter their health status.
T-Continuing the appropriate ♥ Encourage pt and his family the
treatments and follow-up check-up importance of having follow-up
check-up and continuous of the
appropriate treatments.
H- Discuss the importance/ factors that ♥ Explain to the pt. and his family
tend toward the cause and effects of the importance/ risk factors that
his disease lead to the existence of his
disease
(AML (Acute Myelocytic Leukemia) is a
cancer that starts in cells that would
normally develop into different types of

43. 43
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. )
O-Observe the signs and symptoms of ♥ Explain to the pt. and his family
the disease the signs and symptoms of the
disease
- Tiredness or no energy
-Shortness of breath during physical
activity
-Pale skin
-Swollen gums
-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

44. 44
shoulder.
D-Identify the appropriate diet towards ♥ Encourage the pt. & S.O to eat
the recovery of the pt. nutritious foods that is good for
health like eating
vegetables(squash,green-leafy
vegetables,etc.) and
fruits(orange,apple,grapes,etc)
S- Improve spiritual well being towards ♥ Encourage the pt. and his family
personal beliefs and values to acquire spiritual growth and
beliefs(attending masses every
Sunday,praying novena).

45. 45
LEARNING INSIGHTS

46. 46
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
American Cancer Society. Cancer Facts and Figures 2007. Atlanta, GA: American
Cancer Society; 2007
APPENDICES

47. 47
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/mm
3)
Lymphocytes 0 20-50%(1,500-5,500/mm
3)
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
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

48. 48
URINALYSIS
TEST 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
Sodium 136mmol/L 40-220mmol/L
Potassium 3.88mmol/L 3.4-5.2mmol/L
Appendix B

49. 49
DRUG STUDY
A case of 2 year DRUG
NAME OF old, INDICATIONS SIDE EFFECTS
male patient
diagnosed with
Acute Myelocytic
clarithromycin Clarithromycin is useful in • Headache
Leukemia.
(Biaxin) acute worsening of chronic • Diarrhea
bronchitis, community • Abdominal
He complained of
Anti-infectives acquired pneumonia. And pain or
persistent on and off
also used to treat discomfort
fever, and cough
uncomplicated skin and skin • Nausea
thus prompted his
structure infections. • vomiting
admission.
• rash
He has no known
heredo-familial
disease.
acetaminophen for the relief of mild to Side effects of
(Paracetamol) moderate pain, fever, paracetamol are
migraine, tension, rare. Uncommon
analgesic, antipyretic headaches side effects include
indigestion,
nausea, rashes.
Flow of the Study
Input Throughput/Process Output

50. 50
Management Recommendations:
• Medical The patient/S.O is
Figure 1 Management advised to always
Schematic Diagram • Pharmacological maintain a clean
Appendix C Treatment environment, limit
Appendix C visitors, and do ROM
Figure 2 exercises and assistance
in performance of
GENOGRAM: patient’s activities of
daily living.
Prognosis:
Legend: Good- if treated
-Female immediately with
DM - Diabetes chemotherapy and
Mellitus medical mgt.
Poor- if untreated
immediately, it would
lead to sepsis then
eventually death.
- Male HPN - Hypertension
- Patient(male) A - Asthma
† - Died AML -Acute Myelocytic Leukemia
HP
DM A
N

51. 51
A
AML
Appendix D
CURRICULUM VITAE